Robotic surgery, video-assisted thoracic surgery, and open surgery for early stage lung cancer: comparison of costs and outcomes at a single institute.

PubMed

Novellis, Pierluigi; Bottoni, Edoardo; Voulaz, Emanuele; Cariboni, Umberto; Testori, Alberto; Bertolaccini, Luca; Giordano, Laura; Dieci, Elisa; Granato, Lorenzo; Vanni, Elena; Montorsi, Marco; Alloisio, Marco; Veronesi, Giulia

2018-02-01

Robotic surgery is increasingly used to resect lung cancer. However costs are high. We compared costs and outcomes for robotic surgery, video-assisted thoracic surgery (VATS), and open surgery, to treat non-small cell lung cancer (NSCLC). We retrospectively assessed 103 consecutive patients given lobectomy or segmentectomy for clinical stage I or II NSCLC. Three surgeons could choose VATS or open, the fourth could choose between all three techniques. Between-group differences were assessed by Fisher's exact, two-way analysis of variance (ANOVA), and Wilcoxon-Mann-Whitney test. P values <0.05 were considered significant. Twenty-three patients were treated by robot, 41 by VATS, and 39 by open surgery. Age, physical status, pulmonary function, comorbidities, stage, and perioperative complications did not differ between the groups. Pathological tumor size was greater in the open than VATS and robotic groups (P=0.025). Duration of surgery was 150, 191 and 116 minutes, by robotic, VATS and open approaches, respectively (P<0.001). Significantly more lymph node stations were removed (P<0.001), and median length of stay was shorter (4, 5 and 6 days, respectively; P<0.001) in the robotic than VATS and open groups. Estimated costs were 82%, 68% and 69%, respectively, of the regional health service reimbursement for robotic, VATS and open approaches. Robotic surgery for early lung cancer was associated with shorter stay and more extensive lymph node dissection than VATS and open surgery. Duration of surgery was shorter for robotic than VATS. Although the cost of robotic thoracic surgery is high, the hospital makes a profit.

Learning curve for robotic-assisted surgery for rectal cancer: use of the cumulative sum method.

PubMed

Yamaguchi, Tomohiro; Kinugasa, Yusuke; Shiomi, Akio; Sato, Sumito; Yamakawa, Yushi; Kagawa, Hiroyasu; Tomioka, Hiroyuki; Mori, Keita

2015-07-01

Few data are available to assess the learning curve for robotic-assisted surgery for rectal cancer. The aim of the present study was to evaluate the learning curve for robotic-assisted surgery for rectal cancer by a surgeon at a single institute. From December 2011 to August 2013, a total of 80 consecutive patients who underwent robotic-assisted surgery for rectal cancer performed by the same surgeon were included in this study. The learning curve was analyzed using the cumulative sum method. This method was used for all 80 cases, taking into account operative time. Operative procedures included anterior resections in 6 patients, low anterior resections in 46 patients, intersphincteric resections in 22 patients, and abdominoperineal resections in 6 patients. Lateral lymph node dissection was performed in 28 patients. Median operative time was 280 min (range 135-683 min), and median blood loss was 17 mL (range 0-690 mL). No postoperative complications of Clavien-Dindo classification Grade III or IV were encountered. We arranged operative times and calculated cumulative sum values, allowing differentiation of three phases: phase I, Cases 1-25; phase II, Cases 26-50; and phase III, Cases 51-80. Our data suggested three phases of the learning curve in robotic-assisted surgery for rectal cancer. The first 25 cases formed the learning phase.

Surgical flow disruptions during robotic-assisted radical prostatectomy.

PubMed

Dru, Christopher J; Anger, Jennifer T; Souders, Colby P; Bresee, Catherine; Weigl, Matthias; Hallett, Elyse; Catchpole, Ken

2017-06-01

We sought to apply the principles of human factors research to robotic-assisted radical prostatectomy to understand where training and integration challenges lead to suboptimal and inefficient care. Thirty-four robotic-assisted radical prostatectomy and bilateral pelvic lymph node dissections over a 20 week period were observed for flow disruptions (FD) - deviations from optimal care that can compromise safety or efficiency. Other variables - physician experience, trainee involvement, robot model (S versus Si), age, body mass index (BMI), and American Society of Anesthesiologists (ASA) physical status - were used to stratify the data and understand the effect of context. Effects were studied across four operative phases - entry to insufflations, robot docking, surgical intervention, and undocking. FDs were classified into one of nine categories. An average of 9.2 (SD = 3.7) FD/hr were recorded, with the highest rates during robot docking (14.7 [SD = 4.3] FDs/hr). The three most common flow disruptions were disruptions of communication, coordination, and equipment. Physicians with more robotic experience were faster during docking (p < 0.003). Training cases had a greater FD rate (8.5 versus 10.6, p < 0.001), as did the Si model robot (8.2 versus 9.8, p = 0.002). Patient BMI and ASA classification yielded no difference in operative duration, but had phase-specific differences in FD. Our data reflects the demands placed on the OR team by the patient, equipment, environment and context of a robotic surgical intervention, and suggests opportunities to enhance safety, quality, efficiency, and learning in robotic surgery.

Robotic-Assisted Videothoracoscopic Surgery of the Lung.

PubMed

Velez-Cubian, Frank O; Ng, Emily P; Fontaine, Jacques P; Toloza, Eric M

2015-07-01

Despite initial concerns about the general safety of videothoracoscopic surgery, minimally invasive videothoracoscopic surgical procedures have advantages over traditional open thoracic surgery via thoracotomy. Robotic-assisted minimally invasive surgery has expanded to almost every surgical specialty, including thoracic surgery. Adding a robotic-assisted surgical system to a videothoracoscopic surgical procedure corrects several shortcomings of videothoracoscopic surgical cameras and instruments. We performed a literature search on robotic-assisted pulmonary resections and compared the published robotic series data with our experience at the H. Lee Moffitt Cancer Center & Research Institute. All perioperative outcomes, such as intraoperative data, postoperative complications, chest tube duration, hospital length of stay (LOS), and in-hospital mortality rates were noted. Our literature search found 23 series from multiple surgical centers. We divided the literature into 2 groups based on the year published (2005-2010 and 2011-2014). Operative times from earlier studies ranged from 150 to 240 minutes compared with 90 to 242 minutes for later studies. Conversion rates (to open lung resection) from the earlier studies ranged from 0% to 19% compared with 0% to 11% in the later studies. Mortality rates for the earlier studies ranged from 0% to 5% compared with 0% to 2% for the later studies. Since 2010, our group has performed more than 600 robotic-assisted thoracic surgical procedures, including more than 200 robotic-assisted pulmonary lobectomies, which we also divided into 2 groups. Our median skin-to-skin operative time improved from 179 minutes for our early group (n = 104) to 172 minutes for our later group (n = 104). The overall conversion rate was 9.6% and the emergent conversion rate (for bleeding) was 5% for our robotic-assisted lobectomies. The most common postoperative complications in our cohort were prolonged air leak (> 7 days; 16.8%) and atrial fibrillation (12%). Hospital LOS for the early series ranged from 3 to 11 days compared with 2 to 6 days for the later series. Median hospital LOS decreased from 6 to 4 days. Our mortality rate was 1.4%; 3 in-hospital deaths occurred in the early 40 cases. Mediastinal lymph node (LN) dissection and detection of occult mediastinal LN metastases were improved during robotic-assisted lobectomy for non-small-cell lung cancer, as demonstrated by an overall 30% upstaging rate, including a 19% nodal upstaging rate, in our cohort. Robotic-assisted videothoracoscopic pulmonary lobectomy appears to be as safe as conventional videothoracoscopic surgical lobectomy, which has decreased perioperative complications and a shorter hospital LOS than open lobectomy. Both mediastinal LN dissection and the early detection of occult mediastinal LN metastatic disease were improved by robotic-assisted videothoracoscopic surgical compared with conventional videothoracoscopic surgical or open thoracotomy.

Understanding Cognitive Performance During Robot-Assisted Surgery.

PubMed

Guru, Khurshid A; Shafiei, Somayeh B; Khan, Atif; Hussein, Ahmed A; Sharif, Mohamed; Esfahani, Ehsan T

2015-10-01

To understand cognitive function of an expert surgeon in various surgical scenarios while performing robot-assisted surgery. In an Internal Review Board approved study, National Aeronautics and Space Administration-Task Load Index (NASA-TLX) questionnaire with surgical field notes were simultaneously completed. A wireless electroencephalography (EEG) headset was used to monitor brain activity during all procedures. Three key portions were evaluated: lysis of adhesions, extended lymph node dissection, and urethro-vesical anastomosis (UVA). Cognitive metrics extracted were distraction, mental workload, and mental state. In evaluating lysis of adhesions, mental state (EEG) was associated with better performance (NASA-TLX). Utilizing more mental resources resulted in better performance as self-reported. Outcomes of lysis were highly dependent on cognitive function and decision-making skills. In evaluating extended lymph node dissection, there was a negative correlation between distraction level (EEG) and mental demand, physical demand and effort (NASA-TLX). Similar to lysis of adhesion, utilizing more mental resources resulted in better performance (NASA-TLX). Lastly, with UVA, workload (EEG) negatively correlated with mental and temporal demand and was associated with better performance (NASA-TLX). The EEG recorded workload as seen here was a combination of both cognitive performance (finding solution) and motor workload (execution). Majority of workload was contributed by motor workload of an expert surgeon. During UVA, muscle memory and motor skills of expert are keys to completing the UVA. Cognitive analysis shows that expert surgeons utilized different mental resources based on their need. Copyright © 2015 Elsevier Inc. All rights reserved.

Systematic review of perioperative outcomes and complications after open, laparoscopic and robot-assisted radical cystectomy.

PubMed

Palazzetti, A; Sanchez-Salas, R; Capogrosso, P; Barret, E; Cathala, N; Mombet, A; Prapotnich, D; Galiano, M; Rozet, F; Cathelineau, X

2017-09-01

Radical cystectomy and regional lymph node dissection is the standard treatment for localized muscle-invasive and for high-risk non-muscle-invasive bladder cancer, and represents one of the main surgical urologic procedures. The open surgical approach is still widely adopted, even if in the last two decades efforts have been made in order to evaluate if minimally invasive procedures, either laparoscopic or robot-assisted, might show a benefit compared to the standard technique. Open radical cystectomy is associated with a high complication rate, but data from the laparoscopic and robotic surgical series failed to demonstrate a clear reduction in post-operative complication rates compared to the open surgical series. Laparoscopic and robotic radical cystectomy show a reduction in blood loss, in-hospital stay and transfusion rates but a longer operative time, while open radical cystectomy is typically associated with a shorter operative time but with a longer in-hospital admission and possibly a higher rate of high grade complications. Copyright © 2016. Publicado por Elsevier España, S.L.U.

Functional and cosmetic outcomes of robot-assisted neck dissection by a postauricular facelift approach for head and neck cancer.

PubMed

Ji, Yong Bae; Song, Chang Myeon; Bang, Hyang Sook; Park, Hae Jin; Lee, Ji Young; Tae, Kyung

2017-07-01

The purpose of this study was to compare the functional and cosmetic outcomes of robot-assisted neck dissection with those of conventional neck dissection. We prospectively analyzed 113 patients with head and neck cancer who underwent unilateral neck dissection by a robot-assisted postauricular facelift approach (38 patients) or conventional trans-cervical approach (75 patients). Postoperative functional outcomes such as edema, sensory loss, pain, and fibrosis in the neck, and limitations of neck and shoulder motion, and cosmetic satisfaction scored by questionnaire were evaluated serially up to 1year postoperatively, and compared between the two groups. There were differences at baseline clinicopathologic characteristics including age, T classification and stage between the two groups. The mean score of neck edema was lower in the robotic group than that of the conventional group at 1day and 3days postoperatively, and sensory loss was also lower in the robotic group at 1day, 3days and 1week postoperatively (P<0.05). The postoperative cosmetic satisfaction were significantly higher in the robotic group than the conventional group at 1month, 3, 6, and 12months postoperatively. Transient marginal nerve palsy was higher in the robotic group than the conventional group (P=0.043). Postoperative neck edema and sensory loss were lower in the robotic group in the early postoperative period although its clinical significance is not clear. Cosmetic satisfaction was superior in the robotic group. Copyright © 2017 Elsevier Ltd. All rights reserved.

Robotic total thyroidectomy with modified radical neck dissection via unilateral retroauricular approach.

PubMed

Byeon, Hyung Kwon; Holsinger, F Christopher; Tufano, Ralph P; Chung, Hyo Jin; Kim, Won Shik; Koh, Yoon Woo; Choi, Eun Chang

2014-11-01

Traditionally, total thyroidectomy was performed through an open transcervical incision; in cases where there was evident nodal metastasis, the conventional surgical approach was to extend the incision into a large single transverse incision to complete the required neck dissection. However, recent innovation in the surgical technique of thyroidectomy has offered the opportunity to reduce the patient's burden from these prominent surgical scars in the neck. Minimally invasive surgical techniques have been developed and applied by many institutions worldwide, and more recently, various techniques of remote access surgery have been suggested and actively applied.1-6 Since the advent of robotic surgical systems, some have adopted the concept of remote access surgery into developing various robotic thyroidectomy techniques. The more former and widely acknowledged robotic thyroidectomy technique uses a transaxillary (TA) approach, which has been developed by Chung et al. in Korea.7,8 This particular technique has some limitations in the sense that accessing the lymph nodes of the central compartment is troublesome. Terris et al. realized some shortcomings of robotic TA thyroidectomy, especially in their patients in the United States, and developed and reported the feasibility of robotic facelift thyroidectomy.9-13 In cases of thyroid carcinomas with lateral neck node metastases, most abandoned the concept of minimally invasive or remote access surgery and safely adopted conventional open surgical methods to remove the tumor burden. However, Chung et al. have attempted to perform concomitant modified radical neck dissection (MRND) after robotic thyroidectomy through the same TA port.14 This type of robot-assisted neck dissection (RAND) had some inherent limitations, due to fact that lymph nodes of the upper neck were difficult to remove. Over the past few years, we have developed a RAND via modified facelift (MFL) or retroauricular (RA) approach and reported the feasibility and safety of this technique.15, 16 Since then, we have actively applied such RAND techniques in various head and neck cancers. In our country, almost all cases of robotic total thyroidectomy utilize the TA approach. According to the reports made by Terris et al., robotic facelift thyroidectomy technique has been solely applied for ipsilateral hemithyroidectomy. For total thyroidectomy, Terris et al. performed the robotic surgery with bilateral RA incisions. Here, we intend to introduce our novel surgical method after successfully attempting simultaneous robotic total thyroidectomy and RAND via a single RA approach without an axillary incision. To our knowledge, this is the first to report in the medical literature. We present four cases of our surgical experience since the beginning of 2013. All patients received robotic total thyroidectomy with MRND via single RA port without axillary incision after approval from the institutional review board at Severance Hospital, Yonsei University College of Medicine. The inclusion criteria for this operation were as follows: (1) patients with malignant carcinomas of the thyroid gland with evident cervical lymph node metastasis on preoperative imaging studies which are indicated for surgery; (2) patients with no previous history of treatment for thyroid carcinoma. The exclusion criteria were as follows: (1) patients with recurred thyroid tumors; (2) patients with thyroid carcinomas that showed gross invasion to local structures or extensive extrathyroidal capsular spread; (3) patients with clinically evident neck nodal metastasis with extracapsular spread; (4) patients with past history of neck surgery of any kind. In order to assess the extent of disease, neck ultrasonography with fine needle aspiration, neck CT or MRI and PET-CT were performed as preoperative evaluation. All patients were given full information of the possible treatment options for their thyroid cancer comprising of open transcervical approach and robotic surgery via RA approach, including the advantages and disadvantages of each treatment choice and provided written, informed consents before the surgery. General clinical information of the patients is outlined in Table 1. The skin incision for the operation was designed just like the approach for robotic facelift thyroidectomy by Terris et al. and RAND, which has been first reported by our institution.11 (,) 16 The operation was performed by the following sequence. Initially, the skin-subplatysmal flap was elevated after making the skin incision to create sufficient working space. During this process, the elevated skin flap was retracted and maintained by retractors held by the assistant. After application of the self-retaining retractor (Sangdosa Inc., Seoul), neck dissection of the upper neck levels was performed under gross vision. Next, RAND through the RA incision was conducted followed by ipsilateral thyroidectomy with central compartment neck dissection (CCND) via the same approach. Finally, contralateral thyroidectomy with CCND was performed via the single RA port. During these steps, the operator is aided by the bedside assistant with long-suction tips to manipulate and direct the dissected specimen to maintain optimal surgical view or to suck out the fume created by the thermocoagulation from the Harmonic shears. The da Vinci robotic surgical system (Intuitive Surgical, Sunnyvale, CA) was introduced via the RA port with a facedown 30° dual-channel endoscopic arm placed in the center, and two instrument arms equipped at either side with 5-mm Maryland forceps and Harmonic curved shears. During the step of robotic contralateral thyroidectomy, a ProGrasp forceps was utilized at times, instead of 5-mm Maryland forceps. The rest of the surgery was completed with the robotic system (see Video for demonstration of operation for patient 2). Table 1 Clinical characteristics of the patients Patient Sex/age (yr) BMI Side(a) Approach Pathology(b) Tumor size(c) (cm) CCND(d) MRND(d) Drain removal day Drainage amount (ml) Hospital stay (days) 1 F/38 23.8 L RA PC 0.7 2/5 8/23 8 788 11 2 F/18 18.3 L RA PC 0.8 2/8 7/35 6 398 9 3 F/44 23.1 L RA PC 0.9 5/12 5/27 6 607 9 4 F/26 32.9 L RA PC 1.4 3/14 9/48 7 476 15 BMI body mass index, RA retroauricular approach, PC papillary carcinoma, CCND central compartment neck dissection, MRND modified radical neck dissection (a)Side refers to the site of main lesion (b)Pathology refers to the primary tumor within the thyroid gland (c)Tumor size refers to the diameter of the largest tumor in the thyroid gland (d)For each type of lymph node dissection, the number of positive nodes/total number of retrieved nodes is stated For all of the patients, robotic total thyroidectomy with MRND (levels II, III, IV, V) via unilateral RA approach was successfully completed without any significant intraoperative complications or conversion to open or other approach methods. The total operation time was defined as the time from initial skin incision to removal of the final specimen, which was an average 306.1 ± 11.1 min (Table 2). This included the time for skin flap elevation and neck dissection under gross vision (87 ± 2.8 min), setting up the robotic system for RAND (6.8 ± 2.4 min), console time using the robotic system for RAND (59.3 ± 2.2 min), flap elevation for thyroidectomy (11.3 ± 2.5 min), robotic arms docking for ipsilateral thyroidectomy (6.3 ± 2.5 min), console time for ipsilateral thyroidectomy (61.3 ± 2.1 min), robotic arms docking for contralateral thyroidectomy (6.3 ± 2.5 min), and console time for contralateral thyroidectomy (61.8 ± 2.1 min). The working space created from RA incision was sufficient, and manipulations of the robotic instruments through this approach were technically feasible and safe without any mutual collisions throughout the entire operation. It also allowed for an excellent magnified surgical view enabling visualization of important local anatomical structures. There was no postoperative vocal cord palsy due to recurrent laryngeal nerve injury. However, two patients developed transient hypoparathyroidism, which resolved in the end without the need for calcium or vitamin D supplementation after certain period of medical management (Table 3). Also, there was no incidence of postoperative hemorrhage or hematoma formation, although a single patient developed a postoperative seroma on postoperative day 9, which was managed conservatively without the need for further surgical intervention. On average, the wound catheter was removed 6.8 ± 1 days after surgery and the patient was discharged from the hospital at an average 11 ± 2.8 days from admission (Table 1). Final surgical pathology confirmed the diagnosis of papillary carcinoma for every patient. The total number of cervical nodes retrieved from CCND and MRND was 9.8 ± 4 and 33.1 ± 11 respectively, and the number of positive metastatic nodes was 3 ± 1.4 and 7.3 ± 1.7 respectively (Table 1). In three patients (patients 2, 3, and 4), the presence of one parathyroid gland was each verified in the pathology specimen. All four patients have received high-dose (150 mCi) radioiodine ablation (RAI) therapy after the operation and are being followed up (average 11.3 months, range 9-13 months) on a regular basis with no evidence of recurrence (post-RAI, most recent, nonsuppressed thyroglobulin range 0.1-0.4 ng/ml, antithyroglobulin antibody range 13.7-147.5 IU/ml). (ABSTRACT TRUNCATED)

Comparison of surgical performance and short-term clinical outcomes between laparoscopic and robotic surgery in distal gastric cancer.

PubMed

Eom, B W; Yoon, H M; Ryu, K W; Lee, J H; Cho, S J; Lee, J Y; Kim, C G; Choi, I J; Lee, J S; Kook, M C; Rhee, J Y; Park, S R; Kim, Y W

2012-01-01

The authors aimed to compare the surgical performance and the short-term clinical outcomes of robotic assisted laparoscopic distal gastrectomy (RADG) with laparoscopy-assisted distal gastrectomy (LADG) in distal gastric cancer patients. From April 2009 to August 2010, 62 patients underwent LADG and 30 patients underwent RADG for preoperative stage I distal gastric cancer by one surgeon at the National Cancer Center, Korea. Surgical performance was measured using lymph node (LN) dissection time and number of retrieved LNs, which were viewed as surrogates of technical ease and oncologic quality. In clinicopathologic characteristics, mean age, depth of invasion and stage were significantly different between the LADG and RADG group. Mean dissection time at each LN station was greater in the RADG group, but no significant intergroup difference was found for numbers of retrieved LNs. Furthermore, proximal resection margins were smaller, and hospital costs were higher in the RADG group. In terms of the RADG learning curve, mean LN dissection time was smaller in the late RADG group (n = 15) than in the early RADG group (n = 15) for 4sb/4d, 5, 7-12a stations, but numbers of retrieved LNs per station were similar. With the exception of operating time and cost, the numbers of retrieved LNs and the short-term clinical outcomes of RADG were found to be comparable to those of LADG, despite the surgeon's familiarity with LADG and lack of RADG experience. Further studies are needed to evaluate objectively ergonomic comfort and to quantify the patient benefits conferred by robotic surgery. Copyright © 2011 Elsevier Ltd. All rights reserved.

Transperitoneal versus extraperitoneal robotic-assisted radical prostatectomy: which one?

PubMed

Atug, F; Thomas, R

2007-06-01

As robotic surgery has proliferated, both in its availability as well as in its popularity, there are certainly several unresolved matters in the burgeoning field of robotic radical prostatectomy. Matters that are commonly discussed at forums relating to robotic prostatectomy include training, proctoring, overcoming the learning curve, positive surgical margins, quality of life issues, etc. Among the approaches available for robotic radical prostatectomy are the trans-peritoneal (TP) and the extraperitoneal (EP) approaches. Although use of the TP approach vastly outnumbers the EP approach by a wide margin, one must not discount the need for learning the EP approach, especially in patients who could greatly benefit from this approach. The obese, those who have had intraperitoneal procedures in the past, those with ostomies (colostomy, ileostomy) should be considered candidates for the EP approach. For the beginner, it is recommended that familiarizing oneself with the TP approach may be the quickest way to get proficient with use of the robot and for getting over the learning curve, which varies from surgeon to surgeon. Once comfortable with the TP approach, one should consider the application of the EP access, when indicated. One distinct disadvantage of the EP approach is the limited space available for robotic movements. This is why one would prefer getting experience in the TP before forging into the EP approach. Certainly, adequate balloon dissection of the retroperitoneal space above the bladder is critical, as well as additional dissection with the camera in place. Another criticism of the EP approach is the fact that one may not have enough space or ability to perform a complete pelvic lymph node dissection. However, in experienced hands, one is able to do a very comparable job. Though the TP approach would continue to be the premium approach for robotic and laparoscopic radical prostatectomy, one should familiarize oneself with the EP approach since this can clearly be applied to the patient with the correct indication.

Robotic selective neck dissection using a gasless postauricular facelift approach for early head and neck cancer: technical feasibility and safety.

PubMed

Tae, Kyung; Ji, Yong Bae; Song, Chang Myeon; Min, Hyun Jung; Kim, Kyung Rae; Park, Chul Won

2013-03-01

Abstract Background: Scarless and minimally invasive surgery is becoming popular in the head and neck area. We have developed a new robotic selective neck dissection procedure for head and neck squamous cell carcinoma (HNSCC) to avoid a long visible lateral neck scar. Here we report on the technical feasibility and safety of our procedure. We prospectively analyzed 4 patients with early HNSCC who underwent transoral robotic surgery (TORS) and concomitant robotic selective neck dissection via a gasless postauricular facelift approach using the da Vinci(®) Surgical System (Intuitive Surgical Inc., Sunnyvale, CA). Of these patients, 3 were male, and 1 was female. The mean age was 59.0±8.8 years. All patients had tongue cancer, with a clinically negative neck. Three patients were T1, and 1 patient was T2. All patients underwent partial glossectomy by TORS and elective robotic selective neck dissection including levels I, II, and III. The robotic selective neck dissection procedure was completed successfully in all patients. The mean operative time was 276±48 minutes. The mean number of lymph nodes removed was 19.3±7.3. Postoperative hematoma and transient marginal nerve palsy occurred in 1 patient each. Cosmetic satisfaction was excellent in all patients. Preliminary results indicate that robotic selective neck dissection via a gasless postauricular facelift approach is feasible and safe and allows for excellent postoperative cosmesis. Further studies are necessary to determine the oncologic safety and surgical completeness of this procedure compared with conventional neck dissection.

Multispectral Fluorescence Imaging During Robot-assisted Laparoscopic Sentinel Node Biopsy: A First Step Towards a Fluorescence-based Anatomic Roadmap.

PubMed

van den Berg, Nynke S; Buckle, Tessa; KleinJan, Gijs H; van der Poel, Henk G; van Leeuwen, Fijs W B

2017-07-01

During (robot-assisted) sentinel node (SN) biopsy procedures, intraoperative fluorescence imaging can be used to enhance radioguided SN excision. For this combined pre- and intraoperative SN identification was realized using the hybrid SN tracer, indocyanine green- 99m Tc-nanocolloid. Combining this dedicated SN tracer with a lymphangiographic tracer such as fluorescein may further enhance the accuracy of SN biopsy. Clinical evaluation of a multispectral fluorescence guided surgery approach using the dedicated SN tracer ICG- 99m Tc-nanocolloid, the lymphangiographic tracer fluorescein, and a commercially available fluorescence laparoscope. Pilot study in ten patients with prostate cancer. Following ICG- 99m Tc-nanocolloid administration and preoperative lymphoscintigraphy and single-photon emission computed tomograpy imaging, the number and location of SNs were determined. Fluorescein was injected intraprostatically immediately after the patient was anesthetized. A multispectral fluorescence laparoscope was used intraoperatively to identify both fluorescent signatures. Multispectral fluorescence imaging during robot-assisted radical prostatectomy with extended pelvic lymph node dissection and SN biopsy. (1) Number and location of preoperatively identified SNs. (2) Number and location of SNs intraoperatively identified via ICG- 99m Tc-nanocolloid imaging. (3) Rate of intraoperative lymphatic duct identification via fluorescein imaging. (4) Tumor status of excised (sentinel) lymph node(s). (5) Postoperative complications and follow-up. Near-infrared fluorescence imaging of ICG- 99m Tc-nanocolloid visualized 85.3% of the SNs. In 8/10 patients, fluorescein imaging allowed bright and accurate identification of lymphatic ducts, although higher background staining and tracer washout were observed. The main limitation is the small patient population. Our findings indicate that a lymphangiographic tracer can provide additional information during SN biopsy based on ICG- 99m Tc-nanocolloid. The study suggests that multispectral fluorescence image-guided surgery is clinically feasible. We evaluated the concept of surgical fluorescence guidance using differently colored dyes that visualize complementary features. In the future this concept may provide better guidance towards diseased tissue while sparing healthy tissue, and could thus improve functional and oncologic outcomes. Copyright © 2016 European Association of Urology. Published by Elsevier B.V. All rights reserved.

Endolymphatic Ethiodized Oil Intranodal Lymphangiography and Cyanoacrylate Glue Embolization for the Treatment of Postoperative Lymphatic Leak After Robot-Assisted Laparoscopic Pelvic Resection.

PubMed

Hill, Hannah; Srinivasa, Ravi N; Gemmete, Joseph J; Hage, Anthony; Bundy, Jacob; Chick, Jeffrey Forris Beecham

2018-01-01

Purpose: To report the approach, technical success, clinical outcomes, complications, and follow-up of ethiodized oil intranodal lymphangiography with cyanoacrylate glue embolization for the treatment of lymphatic leak after robot-assisted laparoscopic pelvic resection. Materials and Methods: Four men with mean age 68.7 ± 14.3 years were treated with ethiodized oil intranodal lymphangiography with cyanoacrylate embolization for postoperative lymphatic leak. Patients underwent either (1) cystoprostatectomy with ileal conduit and bilateral extensive pelvic lymph node dissection for muscle-invasive urothelial carcinoma and presented with postoperative lymphatic ascites ( n  = 2) or (2) prostatectomy with bilateral standard pelvic lymph node dissection for prostate carcinoma and presented with postoperative pelvic lymphoceles ( n  = 2). Intranodal lymphangiography and embolization procedural details, technical success, clinical outcomes, and follow-up were recorded. Results: In four patients, a total of six ethiodized oil intranodal lymphangiograms were performed, two procedures being repeated interventions. Inguinal lymph node catheterization and ethiodized oil lymphangiography was technically effective in all procedures. A mean of 5.2 ± 2.0 mL of ethiodized oil was used for lymphatic opacification. Cyanoacrylate was diluted to 24.2% with ethiodized oil and 0.44 mL of cyanoacrylate was instilled during first time interventions. On repeat procedures, cyanoacrylate was diluted to 51.7%, and 0.52 mL was instilled. The primary clinical success rate was 50% ( n  = 2/4). Clinical success was achieved in all patients after two interventions ( n  = 4; 100%). No complications were reported at mean follow-up of 134.7 ± 79.2 days (range: 59-248 days). Conclusion: Ethiodized oil intranodal lymphangiography with direct cyanoacrylate glue embolization is a minimally invasive treatment option for lymphatic leak after pelvic resection.

The First 24 Robotic Surgeries of Hospital da Luz.

PubMed

Eurico Reis, João; Santos Silva, João; Costa, Ana Rita; Palma Martelo, Fernando

2017-01-01

Robotic assisted thoracic surgery (RATS) has been growing all over the world, presenting itself as an improvement over video-assisted thoracic surgery (VATS). The main advantages are the precision of the movements, as well as the three-dimensional vision with the consequent perception of the depth of the surgical field. Thus, technically more difficult procedures, such as anatomic segmentectomies and bronchoplastic resections, are facilitated. This surgical approach also improves the quality of mediastinal lymph node dissection, extremely important in lung cancer patients. Analysis of the first 24 robotic thoracic surgeries performed at Hospital da Luz. All robotic thoracic surgeries performed at Hospital da Luz from 2/6/2016 to this date were evaluated, concerning diagnosis, type of surgery, chest drainage time, hospitalization time, morbidity and mortality. Twenty-four RATS were performed, with patients having a mean age of 60.5 (39-76) years, eleven of them being male. All surgeries were performed with 3 ports of 8mm and a 12mm port for the assistant. Eighteen surgeries of pulmonary resection (75%), five surgeries for mediastinal lesions (20.8%), and one for intercostal nerve harvest for reinnervation of the brachial plexus, were performed. In the pulmonary surgeries, eleven were lobectomies (61.1%), five were anatomic segmentectomies (27.8%) and two wedge resections (11.1%). Neoplastic disease was the reason for the sixteen lung anatomic resections, two for metastatic disease and fourteen for primary lung cancer. In each case, a systemic lymph node dissection was performed. All procedures were performed without intra- or postoperative complications. Mean drainage time was 3.4 days [2-6], and mean hospitalization time was 4.8 days [3-8]. There were no mortality or major morbidity. There were two patients with prolonged air-leak up to 6 days. The morbidity after discharge was 12.5%, consisting of an apical pneumothorax that resolved spontaneously, a basal pleural effusion that resolved with outpatient thoracentesis, and a respiratory infection treated with antibiotic. The overall evaluation of this technique is still precocious, but allows to affirm that an experienced surgeon in vats surgery has a faster learning curve with this new approach. The innovation and development of new techniques in thoracic surgery are fundamental in order to allow more effective treatments, with less pain and, when possible, lung parenchyma sparing surgeries in patients with early neoplastic lung disease.

Robotic surgery in complicated gynecologic diseases: experience of Tri-Service General Hospital in Taiwan.

PubMed

Tan, Shun-Jen; Lin, Chi-Kung; Fu, Pei-Te; Liu, Yung-Liang; Sun, Cheng-Chian; Chang, Cheng-Chang; Yu, Mu-Hsien; Lai, Hung-Cheng

2012-03-01

Minimally invasive surgery has been the trend in various specialties and continues to evolve as new technology develops. The development of robotic surgery in gynecology remains in its infancy. The present study reports the first descriptive series of robotic surgery in complicated gynecologic diseases in Taiwan. From March 2009 to February 2011, the records of patients undergoing robotic surgery using the da Vinci Surgical System were reviewed for patient demographics, indications, operative time, hospital stay, conversion to laparotomy, and complications. Sixty cases were reviewed in the present study. Forty-nine patients had benign gynecologic diseases, and 11 patients had malignancies. These robot-assisted laparoscopic procedures include nine hysterectomy, 15 subtotal hysterectomy, 13 myomectomy, eight staging operation, two radical hysterectomy, five ovarian cystectomy, one bilateral salpingo-oophorectomy and myomectomy, two resections of deep pelvic endometriosis, one pelvic adhesiolysis, three sacrocolpopexy and one tuboplasty. Thirty-three patients had prior pelvic surgery, and one had a history of pelvic radiotherapy. Adhesiolysis was necessary in 38 patients to complete the whole operation. Robotic myomectomy was easily accomplished in patients with huge uterus or multiple myomas. The suturing of myometrium or cervical stump after ligation of the uterine arteries minimized the blood loss. In addition, it was much easier to dissect severe pelvic adhesions. The dissection of para-aortic lymph nodes can be easily accomplished. All these surgeries were performed smoothly without ureteral, bladder or bowel injury. The present analyses include various complicated gynecologic conditions, which make the estimation of the effectiveness of robotic surgery in each situation individually not appropriate. However, our experiences do show that robotic surgery is feasible and safe for patients with complicated gynecologic diseases. Copyright © 2012. Published by Elsevier B.V.

Robotic transthoracic esophagectomy.

PubMed

Puntambekar, Shailesh; Kenawadekar, Rahul; Kumar, Sanjay; Joshi, Saurabh; Agarwal, Geetanjali; Reddy, Sunil; Mallik, Jainul

2015-04-23

We have initially published our experience with the robotic transthoracic esophagectomy in 32 patients from a single institute. The present paper is the extension of our experience with robotic system and to best of our knowledge this represents the largest series of robotic transthoracic esophagectomy worldwide. The objective of this study was to investigate the feasibility of the robotic transthoracic esophagectomy for esophageal cancer in a series of patients from a single institute. A retrospective review of medical records was conducted for 83 esophageal cancer patients who underwent robotic esophagectomy at our institute from December 2009 to December 2012. All patients underwent a thorough clinical examination and pre-operative investigations. All patients underwent robotic esophageal mobilization. En-bloc dissection with lymphadenectomy was performed in all cases with preservation of Azygous vein. Relevant data were gathered from medical records. The study population comprised of 50 men and 33 women with mean age of 59.18 years. The mean operative time was 204.94 mins (range 180 to 300). The mean blood loss was 86.75 ml (range 50 to 200). The mean number of lymph node yield was 18. 36 (range 13 to 24). None of the patient required conversion. The mean ICU stay and hospital stay was 1 day (range 1 to 3) and 10.37 days (range 10 to 13), respectively. A total of 16 (19.28%) complication were reported in these patents. Commonly reported complication included dysphagia, pleural effusion and anastomotic leak. No treatment related mortality was observed. After a median follow-up period of 10 months, 66 patients (79.52%) survived with disease free stage. We found robot-assisted thoracoscopic esophagectomy feasible in cases of esophageal cancer. The procedure allowed precise en-bloc dissection with lymphadenectomy in mediastinum with reduced operative time, blood loss and complications.

Robot-assisted radical cystectomy – first Polish clinical outcomes

PubMed Central

Juszczak, Kajetan; Poblocki, Pawel; Mikolajczak, Witold; Drewa, Tomasz

2017-01-01

Introduction Urothelial cell carcinoma is the most common neoplasm of the genito-urinary tract, which, in advanced stages, is treated with radical cystectomy with pelvic lymphadenectomy. It can be performed by an open or minimally invasive approach (laparoscopic and robot-assisted radical cystectomy). Large meta-analyses showed a significantly lower complication rate in the RARC (robot-assisted radical cystectomy) group compared to ORC (open radical cystectomy) in thirty and ninety days after surgery, with similar oncological and functional outcomes. The clinical outcomes of the first forty Polish RARC are explored in this article. Material and methods The Polish Radical Robotic Cystectomy Program (PRRC) was started in 2016 at the Nicolaus Copernicus Hospital in Toruń. Forty consecutive patients, with indications for cystectomy were included into the study. During radical robot-assisted cystectomy, obturator, external, internal, common iliac and presacral lymph nodes were dissected. Oncological outcomes, early complication rate, and the clinical variables were analyzed. Results The mean age in the study group was sixty-seven years, with the majority of patients being overweight and assessed as American Society of Anesthesiology Scale (ASA) – ASA III and ASA IV (2/3 of patients). RARC was performed, with the median time of surgery being 324 minutes (170 minutes being the shortest). Mean blood loss was 365 ml (lowest – 50 ml), and only 2 patients required intraoperative blood transfusion. Twenty patients had ileal conduit, and nineteen had other methods of urinary diversion. Only twenty-nine out of forty patients had minor complications (Clavien I and II), 11 had Clavien III and IV. Clavien V was not present. Only 3 patients required reoperation. Conclusions RARC is a reproducible oncological procedure, which can be safely performed in centers with robotic expertise, with acceptable operative time, complications, and functional and oncologic outcomes. PMID:29732201

Combined Partial Penectomy With Bilateral Robotic Inguinal Lymphadenectomy Using Near-infrared Fluorescence Guidance.

PubMed

Sávio, Luís Felipe; Panizzutti Barboza, Marcelo; Alameddine, Mahmoud; Ahdoot, Michael; Alonzo, David; Ritch, Chad R

2018-03-01

To describe our novel technique for performing a combined partial penectomy and bilateral robotic inguinal lymphadenectomy using intraoperative near-infrared (NIR) fluorescence guidance with indocyanine green (ICG) and the DaVinci Firefly camera system. A 58-year-old man presented status post recent excisional biopsy of a 2-cm lesion on the left coronal aspect of the glans penis. Pathology revealed "invasive squamous cell carcinoma of the penis with multifocal positive margins." His examination was suspicious for cT2 primary and his inguinal nodes were cN0. He was counseled to undergo partial penectomy with possible combined vs staged bilateral robotic inguinal lymphadenectomy. Preoperative computed tomography scan was negative for pathologic lymphadenopathy. Before incision, 5 mL of ICG was injected subcutaneously beneath the tumor. Bilateral thigh pockets were then developed simultaneously and a right, then left robotic modified inguinal lymphadenectomy was performed using NIR fluorescence guidance via the DaVinci Firefly camera. A partial penectomy was then performed in the standard fashion. The combined procedure was performed successfully without complication. Total operative time was 379 minutes and total robotic console time was 95 minutes for the right and 58 minutes to the left. Estimated blood loss on the right and left were 15 and 25 mL, respectively. A total of 24 lymph nodes were retrieved. This video demonstrates a safe and feasible approach for combined partial penectomy and bilateral inguinal lymphadenectomy with NIR guidance using ICG and the DaVinci Firefly camera system. The combined robotic approach has minimal morbidity and avoids the need for a staged procedure. Furthermore, use of NIR guidance with ICG during robotic inguinal lymphadenectomy is feasible and may help identify sentinel lymph nodes and improve the quality of dissection. Further studies are needed to confirm the utility of NIR guidance for robotic sentinel lymph node dissection. Copyright © 2017 Elsevier Inc. All rights reserved.

Current Status of Robot-Assisted Radical Cystectomy: What is the Real Benefit?

PubMed

Takenaka, Atsushi

2015-09-01

In recent years, robot-assisted radical cystectomy has received attention worldwide as a useful procedure that helps to overcome the limitations of open radical cystectomy. We compared the surgical technique, perioperative and oncological outcomes, and learning curve of robot-assisted radical cystectomy with those of open radical cystectomy. The indications for robot-assisted radical cystectomy are identical to those of open radical cystectomy. Relative contraindications are due to patient positioning in the Trendelenburg position for long periods. Urinary diversion is performed either extracorporeally with a small skin incision or intracorporeally with a totally robotic-assisted maneuver. Accordingly, robot-assisted radical cystectomy can be performed safely with an acceptable operative time, little blood loss, and low transfusion rates. The lymph node yield and positive surgical margin rate were not significantly different between robot-assisted radical cystectomy and open radical cystectomy. The survival rates after robot-assisted radical cystectomy are estimated to be similar to that after open radical cystectomy. However, the recurrence pattern is different between robot-assisted radical cystectomy and open radical cystectomy, i.e., extrapelvic lymph node recurrence and peritoneal carcinomatosis were more frequently found in patients who underwent robot-assisted radical cystectomy than in those who underwent open radical cystectomy. Further validation is necessary to prove the feasibility of oncological control. A steep learning curve is one of the benefits of the new technique. The experience of only 50 robot-assisted radical prostatectomies is a minimum requirement for performing feasible robot-assisted radical cystectomy, and surgeons who have performed only 30 surgeries can reach an acceptable level of quality for robot-assisted radical cystectomy.

Robotic nephroureterectomy: a simplified approach requiring no patient repositioning or robot redocking.

PubMed

Zargar, Homayoun; Krishnan, Jayram; Autorino, Riccardo; Akca, Oktay; Brandao, Luis Felipe; Laydner, Humberto; Samarasekera, Dinesh; Ko, Oliver; Haber, Georges-Pascal; Kaouk, Jihad H; Stein, Robert J

2014-10-01

Robotic technology is increasingly adopted in urologic surgery and a variety of techniques has been described for minimally invasive treatment of upper tract urothelial cancer (UTUC). To describe a simplified surgical technique of robot-assisted nephroureterectomy (RANU) and to report our single-center surgical outcomes. Patients with history of UTUC treated with this modality between April 2010 and August 2013 were included in the analysis. Institutional review board approval was obtained. Informed consent was signed by all patients. A simplified single-step RANU not requiring repositioning or robot redocking. Lymph node dissection was performed selectively. Descriptive analysis of patients' characteristics, perioperative outcomes, histopathology, and short-term follow-up data was performed. The analysis included 31 patients (mean age: 72.4±10.6 yr; mean body mass index: 26.6±5.1kg/m(2)). Twenty-six of 30 tumors (86%) were high grade. Mean tumor size was 3.1±1.8cm. Of the 31 patients, 13 (42%) had pT3 stage disease. One periureteric positive margin was noted in a patient with bulky T3 disease. The mean number of lymph nodes removed was 9.4 (standard deviation: 5.6; range: 3-21). Two of 14 patients (14%) had positive lymph nodes on final histology. No patients required a blood transfusion. Six patients experienced complications postoperatively, with only one being a high grade (Clavien 3b) complication. Median hospital stay was 5 d. Within the follow-up period, seven patients experienced bladder recurrences and four patients developed metastatic disease. Our RANU technique eliminates the need for patient repositioning or robot redocking. This technique can be safely reproduced, with surgical outcomes comparable to other established techniques. We describe a surgical technique using the da Vinci robot for a minimally invasive treatment of patients presenting with upper tract urothelial cancer. This technique can be safely implemented with good surgical outcomes. Copyright © 2014 European Association of Urology. Published by Elsevier B.V. All rights reserved.

Cost-analysis comparison of robot-assisted laparoscopic radical cystectomy (RC) vs open RC.

PubMed

Lee, Richard; Chughtai, Bilal; Herman, Michael; Shariat, Shahrokh F; Scherr, Douglas S

2011-09-01

• To systematically review and compare the economic burden of open radical cystectomy (ORC) vs robot-assisted laparoscopic radical cystectomy (RALRC) with pelvic lymph node dissection and urinary diversion. • A Medline search was conducted to identify English language articles regarding RC with urinary diversion. The resulting articles were then further restricted by the terms 'laparoscopic', 'robotic', or 'robotic-assisted'.In all, three articles were identified. • Data from each of these articles were then collected on cost performance in addition to relevant clinical variables, such as length of stay (LOS), operative duration, and complication rates. • When possible, data were subdivided by ileal conduit (IC), continent cutaneous diversion (CCD), and orthotopic neobladder (ON) subgroups. • Direct costs resulting from ORC or RALRC with accompanying hospitalization were identified. The indirect costs of complications were considered. • Despite an increased materials cost, RALRC was less expensive than ORC when the cost of complications was considered. • RALRC was less expensive than ORC for IC and CCD, but the cost advantage deteriorated for ON. • The largest cost drivers cited in the published data were LOS, operative durations, and daily hospitalizations costs. • RALRC demonstrated shorter LOS compared with ORC, although this effect was insufficient to offset the increased cost of robotic surgery. • Complications materially affected cost performance. • Despite an increased materials cost, RALRC can be more cost efficient than ORC as a treatment for bladder cancer when the impact of complications are considered. • This effect is most pronounced for patients undergoing IC. © 2011 THE AUTHORS. BJU INTERNATIONAL © 2011 BJU INTERNATIONAL.

Optimisation of fluorescence guidance during robot-assisted laparoscopic sentinel node biopsy for prostate cancer.

PubMed

KleinJan, Gijs H; van den Berg, Nynke S; Brouwer, Oscar R; de Jong, Jeroen; Acar, Cenk; Wit, Esther M; Vegt, Erik; van der Noort, Vincent; Valdés Olmos, Renato A; van Leeuwen, Fijs W B; van der Poel, Henk G

2014-12-01

The hybrid tracer was introduced to complement intraoperative radiotracing towards the sentinel nodes (SNs) with fluorescence guidance. Improve in vivo fluorescence-based SN identification for prostate cancer by optimising hybrid tracer preparation, injection technique, and fluorescence imaging hardware. Forty patients with a Briganti nomogram-based risk >10% of lymph node (LN) metastases were included. After intraprostatic tracer injection, SN mapping was performed (lymphoscintigraphy and single-photon emission computed tomography with computed tomography (SPECT-CT)). In groups 1 and 2, SNs were pursued intraoperatively using a laparoscopic gamma probe followed by fluorescence imaging (FI). In group 3, SNs were initially located via FI. Compared with group 1, in groups 2 and 3, a new tracer formulation was introduced that had a reduced total injected volume (2.0 ml vs. 3.2 ml) but increased particle concentration. For groups 1 and 2, the Tricam SLII with D-Light C laparoscopic FI (LFI) system was used. In group 3, the LFI system was upgraded to an Image 1 HUB HD with D-Light P system. Hybrid tracer-based SN biopsy, extended pelvic lymph node dissection, and robot-assisted radical prostatectomy. Number and location of the preoperatively identified SNs, in vivo fluorescence-based SN identification rate, tumour status of SNs and LNs, postoperative complications, and biochemical recurrence (BCR). Mean fluorescence-based SN identification improved from 63.7% (group 1) to 85.2% and 93.5% for groups 2 and 3, respectively (p=0.012). No differences in postoperative complications were found. BCR occurred in three pN0 patients. Stepwise optimisation of the hybrid tracer formulation and the LFI system led to a significant improvement in fluorescence-assisted SN identification. Preoperative SPECT-CT remained essential for guiding intraoperative SN localisation. Intraoperative fluorescence-based SN visualisation can be improved by enhancing the hybrid tracer formulation and laparoscopic fluorescence imaging system. Copyright © 2014 European Association of Urology. Published by Elsevier B.V. All rights reserved.

Robot-assisted hysterectomy for endometrial and cervical cancers: a systematic review.

PubMed

Nevis, Immaculate F; Vali, Bahareh; Higgins, Caroline; Dhalla, Irfan; Urbach, David; Bernardini, Marcus Q

2017-03-01

Total and radical hysterectomies are the most common treatment strategies for early-stage endometrial and cervical cancers, respectively. Surgical modalities include open surgery, laparoscopy, and more recently, minimally invasive robot-assisted surgery. We searched several electronic databases for randomized controlled trials and observational studies with a comparison group, published between 2009 and 2014. Our outcomes of interest included both perioperative and morbidity outcomes. We included 35 observational studies in this review. We did not find any randomized controlled trials. The quality of evidence for all reported outcomes was very low. For women with endometrial cancer, we found that there was a reduction in estimated blood loss between the robot-assisted surgery compared to both laparoscopy and open surgery. There was a reduction in length of hospital stay between robot-assisted surgery and open surgery but not laparoscopy. There was no difference in total lymph node removal between the three modalities. There was no difference in the rate of overall complications between the robot-assisted technique and laparoscopy. For women with cervical cancer, there were no differences in estimated blood loss or removal of lymph nodes between robot-assisted and laparoscopic procedure. Compared to laparotomy, robot-assisted hysterectomy for cervical cancer showed an overall reduction in estimated blood loss. Although robot-assisted hysterectomy is clinically effective for the treatment of both endometrial and cervical cancers, methodologically rigorous studies are lacking to draw definitive conclusions.

Unilateral robotic hybrid mini-maze: a novel experimental approach.

PubMed

Moslemi, Mohammad; Rawashdeh, Badi; Meyer, Mark; Nguyen, Duy; Poston, Robert; Gharagozloo, Farid

2016-03-01

A complete Cox maze IV procedure is difficult to accomplish using current endoscopic and minimally invasive techniques. These techniques are hampered by inability to adequately dissect the posterior structures of the heart and place all necessary lesions. We present a novel approach, using robotic technology, that achieves placement of all the lesions of the complete maze procedure. In three cadaveric human models, the technical feasibility of using robotic instruments through the right chest to dissect the posterior structures of the heart and place all Cox maze lesions was performed. The entire posterior aspect of the heart was dissected in the cadaveric model facilitating successful placement of all Cox maze IV lesions with robotic assistance through minimally invasive incisions. The robotic Cox maze IV procedure through the novel right thoracic approach is feasible. This obviates the need for sternotomy and avoids the associated morbidity of the conventional Cox-maze procedure. Copyright © 2015 John Wiley & Sons, Ltd.

Assessing the safety and efficacy of full robotic gastrectomy with intracorporeal robot-sewn anastomosis for gastric cancer: A randomized clinical trial.

PubMed

Wang, Gang; Jiang, Zhiwei; Zhao, Jian; Liu, Jiang; Zhang, Shu; Zhao, Kun; Feng, Xiaobo; Li, Jieshou

2016-03-01

Robotic gastrectomy is increasingly used in gastric cancer patients. This study assessed the safety and efficacy of full robotic gastrectomy with intracorporeal robot-sewn anastomosis for gastric cancer. Three hundred and eleven patients were randomized into an open gastrectomy group or a robotic gastrectomy group, and digestive restorations were performed under direct vision and with intracorporeal robot-sewn anastomosis, respectively. Length of postoperative hospital stay, number of lymph node dissections, surgical duration, blood loss, and complication rate after surgery were recorded. There were no significant differences in the number of lymph node dissections (30.9 ± 10.4 vs. 29.3 ± 9.7 days, P = 0.281) or complication rates (10.3 vs. 9.3%, P = 0.756) between the two groups. Surgical duration was significantly longer in the robotic gastrectomy group than in the open gastrectomy group (242.7 ± 43.8 vs. 192.4 ± 31.5 min, P = 0.002), whereas blood loss was less (94.2 ± 51.5 vs. 152.8 ± 76.9 ml, P < 0.001), length of postoperative hospital stay was shorter (5.6 ± 1.9 vs. 6.7 ± 1.9 days, P = 0.021), and postoperative restoration of bowel function was earlier (2.6 ± 1.1 vs. 3.1 ± 1.2 days, P = 0.028). Full robotic gastrectomy with intracorporeal robot-sewn anastomosis for gastric cancer is safe and does not increase the complication risk during or after surgery. J. Surg. Oncol. 2016;113:397-404. © 2016 Wiley Periodicals, Inc. © 2016 Wiley Periodicals, Inc.

The da Vinci robotic surgical assisted anterior lumbar interbody fusion: technical development and case report.

PubMed

Beutler, William J; Peppelman, Walter C; DiMarco, Luciano A

2013-02-15

Technique development to use the da Vince Robotic Surgical System for anterior lumbar interbody fusion at L5-S1 is detailed. A case report is also presented. To evaluate and develop the da Vinci robotic assisted laparoscopic anterior lumbar stand-alone interbody fusion procedure. Anterior lumbar interbody fusion is a common procedure associated with potential morbidity related to the surgical approach. The da Vinci robot provides intra-abdominal dissection and visualization advantages compared with the traditional open and laparoscopic approach. The surgical techniques for approach to the anterior lumbar spine using the da Vinci robot were developed and modified progressively beginning with operative models followed by placement of an interbody fusion cage in the living porcine model. Development continued to progress with placement of fusion cage in a human cadaver, completed first in the laboratory setting and then in the operating room. Finally, the first patient with fusion completed using the da Vinci robot-assisted approach is presented. The anterior transperitoneal approach to the lumbar spine is accomplished with enhanced visualization and dissection capability, with maintenance of pneumoperitoneum using the da Vinci robot. Blood loss is minimal. The visualization inside the disc space and surrounding structures was considered better than current open and laparoscopic techniques. The da Vinci robot Surgical System technique continues to develop and is now described for the transperitoneal approach to the anterior lumbar spine. 4.

Survey of practicing urologists: robotic versus open radical prostatectomy.

PubMed

Lee, Eugene K; Baack, Janet; Duchene, David A

2010-04-01

The robotic assisted radical prostatectomy (RARP) has become the most common operative choice for localized prostate cancer. At our institution, we have also seen a substantial increase in the proportion of RARP. Possible patient factors may include marketing, increased Internet usage by patients, and patient-to-patient communication. We surveyed urologists from the central United States to determine possible surgeon factors for the popularity of the RARP. We mailed a survey to all urologists in the South Central Section of the American Urological Association. After demographic information was obtained, participants were asked to choose an operation for themselves based on two prostate cancer scenarios; low risk and high risk. For the low risk prostate cancer scenario, 54.3% chose RARP while 32.9% chose a radical retropubic prostatectomy (RRP). In the high risk scenario, 32.3% chose a RARP while 58.8% chose the RRP. The top reasons for choosing robotics included decreased blood loss, better pain control, and visualization of the apex. The most popular reasons for an open operation included improved lymph node dissection, better tactile sensation, and easier operation for the surgeon. The two most important factors for choosing a particular operation were cancer control and the urologist performing the operation. Also, urologists favored the operative choice in which he or she performed. Robotic assisted radical prostatectomy has become the favored operative approach for low risk prostate cancer. However, many urologists still feel an oncologic difference may exist between open and robotic surgery as evidenced by more urologists favoring an open approach for high risk prostate cancer.

Initial multicentre experience of 68 gallium-PSMA PET/CT guided robot-assisted salvage lymphadenectomy: acceptable safety profile but oncological benefit appears limited.

PubMed

Siriwardana, Amila; Thompson, James; van Leeuwen, Pim J; Doig, Shaela; Kalsbeek, Anton; Emmett, Louise; Delprado, Warick; Wong, David; Samaratunga, Hemamali; Haynes, Anne-Maree; Coughlin, Geoff; Stricker, Phillip

2017-11-01

To evaluate the safety and short-term oncological outcomes of 68 gallium-labelled prostate-specific membrane antigen ( 68 Ga-PSMA) positron-emission tomography (PET)/computed tomography (CT)-directed robot-assisted salvage node dissection (RASND) for prostate cancer oligometastatic nodal recurrence. Between February 2014 and April 2016, 35 patients across two centres underwent RASND for 68 Ga-PSMA PET/CT-detected oligometastatic nodal recurrence. RASND was performed using targeted pelvic dissection, unilateral extended pelvic template or bilateral extended pelvic template dissection, depending on previous pelvic treatment and extent/location of nodal disease. Complications were reported using the Clavien-Dindo classification system. Definitions of prostate-specific antigen (PSA) treatment response to RASND were defined as 6-week PSA <0.2 ng/mL (broad definition) or PSA <0.05 ng/mL (strict definition) in those who had undergone primary prostatectomy, and 6-week PSA level < post-radiotherapy nadir in those who had undergone primary radiotherapy. Biochemical recurrence (BCR) after RASND was defined as a PSA >0.2 ng/mL or PSA > nadir, for those who had undergone primary prostatectomy and primary radiotherapy, respectively. Predictors of treatment response were analysed using univariate binary logistic regression. A total of 58 lesions suspicious for lymph node metastases (LNM) in 35 patients were detected on 68 Ga-PSMA imaging. A total of 32 patients (91%) had histopathologically proven LNM at RASND, with a total of 87 LNM and a median (interquartile range) of 2 (1-3) LNM per patient. In all, eight patients (23%) experienced complications, all Clavien-Dindo grade ≤2. Treatment response was seen in 15 (43%) and 11 patients (31%), using the broad and strict definitions, respectively. BCR-free survival and clinical recurrence-free survival at a median follow-up of 12 months were 23% and 66%, respectively, for the entire cohort. Bilateral template dissection was the only significant univariate predictor of treatment response in our cohort. Although RASND appears safe and feasible, less than half of our cohort had a treatment response, and less than a quarter experienced BCR-free survival at 12-month median follow-up. 68 Ga-PSMA imaging underestimates micro-metastatic disease, therefore RASND will rarely be curative. Strict patient selection and restricting RASND to clinical trials is recommended. Long-term follow-up from such trials is required to further assess potential quality of life and mortality benefits. © 2017 The Authors BJU International © 2017 BJU International Published by John Wiley & Sons Ltd.

Timing of neck dissection in patients undergoing transoral robotic surgery for head and neck cancer.

PubMed

Möckelmann, N; Busch, C-J; Münscher, A; Knecht, R; Lörincz, B B

2015-06-01

Oncologic transoral robotic surgery (TORS) requires in most cases the concurrent or staged surgical treatment of the regional lymph nodes in the neck as well. The purpose of this study was to determine whether the timing of the regional lymphadenectomy (neck dissection) has an impact on the surgical outcomes and on the complication rates. Single-institution, prospective case series with internal control group. Twenty-one patients underwent TORS and appropriate neck dissection concurrently (control group), while 20 patients underwent neck dissection in a timely staged fashion, 8.4 days (median; range, 3-28 days) following their TORS procedure (experimental group). Outcome measures included nodal yield, intraoperative pharyngocervical fistula formation, postoperative fistula formation, postoperative bleeding from the primary and from the neck dissection site, haematoma, seroma, and infection. Nodal yield values, as the oncologic quality indicator of a neck dissection, were comparable in the experimental and in the control group. Complication rates did not differ between the groups: intraoperative and postoperative fistula formation, postoperative bleeding, haematoma and seroma rates were similarly low in the two groups. There was no infection in either group. In the present cohort of 41 TORS-patients, the timing of neck dissection did not make a significant difference in the outcomes. We suggest therefore that aspiring and established TORS-teams do not restrict their appropriate indications due to robotic slot and theatre time constraints, but perform each indicated TORS-case as soon as possible within their given systems, even if the neck dissections cannot be done on the same day. Copyright © 2015 Elsevier Ltd. All rights reserved.

Use of the Endoholder device during robotic-assisted laparoscopic radical prostatectomy: the "poor man's" fourth arm equivalent.

PubMed

Zorn, Kevin C; Gofrit, Ofer N; Zagaja, Gregory P; Shalhav, Arieh L

2008-02-01

During standard, six-port set-up, robotic-assisted laparoscopic radical prostatectomy (RLRP) using a three-arm daVinci system (DVS), two assistants are routinely required. The role of the second assistant is often limited to isometric traction during prostate dissection. Due to muscle fatigue and inability of the operator to see the operative field, frequent repositioning of the second assistant is often required. In an attempt to improve efficiency in such surgical situations, we describe the use of the Endoholder, an adjustable articulating instrument holder, to assist during RLRP. During 100 consecutive cases, the Endoholder provided quick, reproducible retraction to facilitate exposure. No complications occurred with its use. The device reduced the need for a dedicated second assistant to stand bedside. We have achieved significant improvements in the safety and efficiency of retraction of the rectum, bladder, and prostate during RLRP with the Endoholder. For urologists working with a three-armed DVS, use of the Endoholder may help facilitate tissue retraction during dissection.

Development and validation of surgical training tool: cystectomy assessment and surgical evaluation (CASE) for robot-assisted radical cystectomy for men.

PubMed

Hussein, Ahmed A; Sexton, Kevin J; May, Paul R; Meng, Maxwell V; Hosseini, Abolfazl; Eun, Daniel D; Daneshmand, Siamak; Bochner, Bernard H; Peabody, James O; Abaza, Ronney; Skinner, Eila C; Hautmann, Richard E; Guru, Khurshid A

2018-04-13

We aimed to develop a structured scoring tool: cystectomy assessment and surgical evaluation (CASE) that objectively measures and quantifies performance during robot-assisted radical cystectomy (RARC) for men. A multinational 10-surgeon expert panel collaborated towards development and validation of CASE. The critical steps of RARC in men were deconstructed into nine key domains, each assessed by five anchors. Content validation was done utilizing the Delphi methodology. Each anchor was assessed in terms of context, score concordance, and clarity. The content validity index (CVI) was calculated for each aspect. A CVI ≥ 0.75 represented consensus, and this statement was removed from the next round. This process was repeated until consensus was achieved for all statements. CASE was used to assess de-identified videos of RARC to determine reliability and construct validity. Linearly weighted percent agreement was used to assess inter-rater reliability (IRR). A logit model for odds ratio (OR) was used to assess construct validation. The expert panel reached consensus on CASE after four rounds. The final eight domains of the CASE included: pelvic lymph node dissection, development of the peri-ureteral space, lateral pelvic space, anterior rectal space, control of the vascular pedicle, anterior vesical space, control of the dorsal venous complex, and apical dissection. IRR > 0.6 was achieved for all eight domains. Experts outperformed trainees across all domains. We developed and validated a reliable structured, procedure-specific tool for objective evaluation of surgical performance during RARC. CASE may help differentiate novice from expert performances.

Erectile Function and Oncologic Outcomes Following Open Retropubic and Robot-assisted Radical Prostatectomy: Results from the LAParoscopic Prostatectomy Robot Open Trial.

PubMed

Sooriakumaran, Prasanna; Pini, Giovannalberto; Nyberg, Tommy; Derogar, Maryam; Carlsson, Stefan; Stranne, Johan; Bjartell, Anders; Hugosson, Jonas; Steineck, Gunnar; Wiklund, Peter N

2018-04-01

Whether surgeons perform better utilising a robot-assisted laparoscopic technique compared with an open approach during prostate cancer surgery is debatable. To report erectile function and early oncologic outcomes for both surgical modalities, stratified by prostate cancer risk grouping. In a prospective nonrandomised trial, we recruited 2545 men with prostate cancer from seven open (n=753) and seven robot-assisted (n=1792) Swedish centres (2008-2011). Clinometrically-validated questionnaire-based patient-reported erectile function was collected before, 3 mo, 12 mo, and 24 mo after surgery. Surgeon-reported degree of neurovascular-bundle preservation, pathologist-reported positive surgical margin (PSM) rates, and 2-yr prostate-specific antigen-relapse rates were measured. Among 1702 preoperatively potent men, we found enhanced erectile function recovery for low/intermediate-risk patients in the robot-assisted group at 3 mo. For patients with high-risk tumours, point estimates for erectile function recovery at 24 mo favoured the open surgery group. The degree of neurovascular bundle preservation and erectile function recovery were greater correlated for robot-assisted surgery. In pT2 tumours, 10% versus 17% PSM rates were observed for open and robot-assisted surgery, respectively; corresponding rates for pT3 tumours were 48% and 33%. These differences were associated with biochemical recurrence in pT3 but not pT2 disease. The study is limited by its nonrandomised design and relatively short follow-up. Earlier recovery of erectile function in the robot-assisted surgery group in lower-risk patients is counterbalanced by lower PSM rates for open surgeons in organ-confined disease; thus, both open and robotic surgeons need to consider this trade-off when determining the plane of surgical dissection. Robot-assisted surgery also facilitates easier identification of nerve preservation planes during radical prostatectomy as well as wider dissection for pT3 cases. For prostate cancer surgery, an open operation reduces erection problems in high-risk cancers but has higher relapse rates than robotic surgery. Relapse rates appear similar in low/intermediate-risk cancers and the robot appears better at preserving erections in these cases. Copyright © 2017 European Association of Urology. Published by Elsevier B.V. All rights reserved.

VEIL Surgical Steps.

PubMed

Raghunath, S K; Nagaraja, H; Srivatsa, N

2017-03-01

Inguinal lymphadenectomy remains the standard of care for metastatic nodal disease in cases of penile, urethral, vulval and vaginal cancers. Outcomes, including cure rates and overall and progression-free survivals, have progressively improved in these diseases with extending criteria to offer inguinal lymph node dissection for patients 'at-risk' for metastasis or loco-regional recurrence. Hence, despite declining incidence of advanced stages of these cancers, many patients will still need to undergo lymphadenectomy for optimal oncological outcomes. Inguinal node dissection is a morbid procedure with operative morbidity noted in almost two third of the patients. Video endoscopic inguinal lymphadenectomy (VEIL) was described and currently practiced with proven equivalent oncological outcomes. We describe our technique of VEIL using laparoscopic and robotic access as well as various new surgical strategies.

Transition from a multiport technique to a single-port technique for lung cancer surgery: is lymph node dissection inferior using the single-port technique?†.

PubMed

Liu, Chia-Chuan; Shih, Chih-Shiun; Pennarun, Nicolas; Cheng, Chih-Tao

2016-01-01

The feasibility and radicalism of lymph node dissection for lung cancer surgery by a single-port technique has frequently been challenged. We performed a retrospective cohort study to investigate this issue. Two chest surgeons initiated multiple-port thoracoscopic surgery in a 180-bed cancer centre in 2005 and shifted to a single-port technique gradually after 2010. Data, including demographic and clinical information, from 389 patients receiving multiport thoracoscopic lobectomy or segmentectomy and 149 consecutive patients undergoing either single-port lobectomy or segmentectomy for primary non-small-cell lung cancer were retrieved and entered for statistical analysis by multivariable linear regression models and Box-Cox transformed multivariable analysis. The mean number of total dissected lymph nodes in the lobectomy group was 28.5 ± 11.7 for the single-port group versus 25.2 ± 11.3 for the multiport group; the mean number of total dissected lymph nodes in the segmentectomy group was 19.5 ± 10.8 for the single-port group versus 17.9 ± 10.3 for the multiport group. In linear multivariable and after Box-Cox transformed multivariable analyses, the single-port approach was still associated with a higher total number of dissected lymph nodes. The total number of dissected lymph nodes for primary lung cancer surgery by single-port video-assisted thoracoscopic surgery (VATS) was higher than by multiport VATS in univariable, multivariable linear regression and Box-Cox transformed multivariable analyses. This study confirmed that highly effective lymph node dissection could be achieved through single-port VATS in our setting. © The Author 2015. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.

The efficacy and utilisation of preoperative multiparametric magnetic resonance imaging in robot-assisted radical prostatectomy: does it change the surgical dissection plan?

PubMed

Tavukçu, Hasan Hüseyin; Aytaç, Ömer; Balcı, Numan Cem; Kulaksızoğlu, Haluk; Atuğ, Fatih

2017-12-01

We investigated the effect of the use of multiparametric prostate magnetic resonance imaging (mp-MRI) on the dissection plan of the neurovascular bundle and the oncological results of our patients who underwent robot-assisted radical prostatectomy. We prospectively evaluated 60 consecutive patients, including 30 patients who had (Group 1), and 30 patients who had not (Group 2) mp-MRI before robot-assisted radical prostatectomy. Based on the findings of mp-MRI, the dissection plan was changed as intrafascial, interfascial, and extrafascial in the mp-MRI group. Two groups were compared in terms of age, prostate-specific antigen (PSA), Gleason sum scores and surgical margin positivity. There was no statistically significant difference between the two groups in terms of age, PSA, biopsy Gleason score, final pathological Gleason score and surgical margin positivity. mp-MRI changed the initial surgical plan in 18 of 30 patients (60%) in Group 1. In seventeen of these patients (56%) surgical plan was changed from non-nerve sparing to interfascial nerve sparing plan. In one patient dissection plan was changed to non-nerve sparing technique which had extraprostatic extension on final pathology. Surgical margin positivity was similar in Groups 1, and 2 (16% and 13%, respectively) although, Group 1 had higher number of high- risk patients. mp-MRI confirmed the primary tumour localisation in the final pathology in 27 of of 30 patients (90%). Preoperative mp-MRI effected the decision to perform a nerve-sparing technique in 56% of the patients in our study; moreover, changing the dissection plan from non-nerve-sparing technique to a nerve sparing technique did not increase the rate of surgical margin positivity.

Robotic versus laparoscopic proctectomy for rectal cancer: a meta-analysis.

PubMed

Memon, Sameer; Heriot, Alexander G; Murphy, Declan G; Bressel, Mathias; Lynch, A Craig

2012-07-01

Robot-assisted laparoscopic surgery is being performed more frequently for the minimally invasive management of rectal cancer. The objective of this meta-analysis was to compare the clinical and oncologic safety and efficacy of robot-assisted versus conventional laparoscopic surgery. A search of the Medline and Embase databases was performed for studies that compared clinical or oncologic outcomes of conventional laparoscopic proctectomy with robot-assisted laparoscopic proctectomy for rectal cancer. The methodological quality of the selected studies was critically assessed to identify studies suitable for inclusion. Meta-analysis was performed by a random effects model and analyzed by Review Manager. Clinical outcomes evaluated were conversion rates, operation times, length of hospital stay, and complications. Oncologic outcomes evaluated were circumferential margin status, number of lymph nodes collected, and distal resection margin lengths. Eight comparative studies were assessed for quality, and seven studies were included in the meta-analysis. Two studies were matched case-control studies, and five were unmatched. A total of 353 robot-assisted laparoscopic surgery proctectomy cases and 401 conventional laparoscopic surgery proctectomy cases were analyzed. Robotic surgery was associated with a significantly lower conversion rate (P=0.03; 95% confidence interval 1-12). There was no difference in complications, circumferential margin involvement, distal resection margin, lymph node yield, or hospital stay (P=NS). Robot-assisted surgery decreased the conversion rate compared to conventional laparoscopic surgery. Other clinical outcomes and oncologic outcomes were equivalent. The benefits of robotic rectal cancer surgery may differ between population groups.

Robotic Low Ligation of the Inferior Mesenteric Artery for Rectal Cancer Using the Firefly Technique.

PubMed

Bae, Sung Uk; Min, Byung Soh; Kim, Nam Kyu

2015-07-01

By integrating intraoperative near infrared fluorescence imaging into a robotic system, surgeons can identify the vascular anatomy in real-time with the technical advantages of robotics that is useful for meticulous lymphovascular dissection. Herein, we report our initial experience of robotic low ligation of the inferior mesenteric artery (IMA) with real-time identification of the vascular system for rectal cancer using the Firefly technique. The study group included 11 patients who underwent a robotic total mesorectal excision with preservation of the left colic artery for rectal cancer using the Firefly technique between July 2013 and December 2013. The procedures included five low anterior resections and six ultra-low anterior resections with loop ileostomy. The median total operation time was 327 min (226-490). The low ligation time was 10 min (6-20), and the time interval between indocyanine green injection and division of the sigmoid artery was 5 min (2-8). The estimated blood loss was 200 mL (100-500). The median time to soft diet was 4 days (4-5), and the median length of stay was 7 days (5-9). Three patients developed postoperative complications; one patients developed anal stricture, one developed ileus, and one developed non-complicated intraabdominal fluid collection. The median total number of lymph nodes harvested was 17 (9-29). Robotic low ligation of the IMA with real-time identification of the vascular system for rectal cancer using the Firefly technique is safe and feasible. This technique can allow for precise lymph node dissection along the IMA and facilitate the identification of the left colic branch of the IMA.

[Discussion on standardized implementation of laparoscopic radical lymphadenectomy for distal gastric cancer].

PubMed

Lyu, Zejian; Wang, Junjiang; Li, Yong

2017-08-25

Laparoscopic radical gastrectomy for gastric cancer has been widely applied in clinical practice, and its indications have been extended from early gastric cancer to advanced gastric cancer. It is acknowledged that laparoscopic radical gastrectomy is technically challenging because of the complexity of anatomy, rich blood supply, and extensive lymph node dissection. This paper primarily intends to share the experience of laparoscopic radical D2 gastrectomy for distal gastric cancer with details of choosing the location of Trocar, surgical approaches and the sequence of lymph node dissection. All the surgeries were performed at Department of General Surgery and Gastrointestinal Surgery, Guangdong General Hospital. The finding suggests that a correct laparoscopic Trocar placement is the foundation of adequate surgical field visualization. Under most circumstances, the observation hole should be around 2 cm below the umbilicus and the operating hole should be close to the bilateral clavicle midline. Furthermore, proper surgical approach and sequence of lymph node dissection are the prerequisites for successful laparoscopic radical D2 gastrectomy, as well as the reassurance of dissecting lymph node safely and comprehensively. The position of surgical team adopted in our center is that the surgeon stands to the left of the patient, with laparoscope operator stands in between patient's legs while the first assistant positions himself opposite the surgeon on the right side of the patient. This position correlates to the rules of sequential lymph node dissection, which is "from left to right", "from proximal to distal" and "from inferior to superior". Therefore, it is conductive to inferior and superior pylorus region dissection and it can effectively prevent subsidiary-injury. In our center, the procedure of lymph node dissection has been standardized: the initial step is to undergo station 4sb dissection and greater gastric curvature clearance; then change the patient's position to clean the sub-pyloric lymph node region and cut off the duodenum by linear stapler; followed by the clearance of inferior region of the pylorus and the upper margin of the pancreas; in the final step, the first and the third groups of lymph node dissection is performed. Although varied surgical approaches and sequences of lymph node dissection are applied in different hospitals, the techniques required for laparoscopic D2 radical gastrectomy for gastric cancer are sophisticated and advanced in general. Radical lymph node dissection is complicated, urging surgeons to familiarize themselves with the anatomy of gastric peripheral vascular system and characteristics of lymph node drainage. By designing and implementing effective strategies, such as formulating a regular team, positioning surgical team reasonably, changing a patient's posture during operation, choosing an appropriate surgical approach and following a logically sequence of lymph node dissection, surgeons can standardize the complete surgical procedure, which ultimately reduces bleeding during surgery and shortens the operative time.

Robot-assisted Versus Laparoscopic Surgery for Rectal Cancer: A Phase II Open Label Prospective Randomized Controlled Trial.

PubMed

Kim, Min Jung; Park, Sung Chan; Park, Ji Won; Chang, Hee Jin; Kim, Dae Yong; Nam, Byung-Ho; Sohn, Dae Kyung; Oh, Jae Hwan

2018-02-01

The phase II randomized controlled trial aimed to compare the outcomes of robot-assisted surgery with those of laparoscopic surgery in the patients with rectal cancer. The feasibility of robot-assisted surgery over laparoscopic surgery for rectal cancer has not been established yet. Between February 21, 2012 and March 11, 2015, patients with rectal cancer (cT1-3NxM0) were enrolled. Patients were randomized 1:1 to either robot-assisted or laparoscopic surgery, and stratified per sex and administration of preoperative chemoradiotherapy. The primary outcome was the quality of total mesorectal excision (TME) specimen. Secondary outcomes were the circumferential and distal resection margins, the number of harvested lymph nodes, morbidity, bowel function recovery, and quality of life. A total of 163 patients were randomly assigned to the robot-assisted (n = 81) and laparoscopic (n = 82) surgery groups, and 139 patients were eligible for the analyses (73 vs 66, respectively). One patient (1.2%) in the robot-assisted group was converted to open surgery. The TME quality did not differ between the robot-assisted and laparoscopic groups (80.3% vs 78.1% complete TME, respectively; 18.2% vs 21.9% nearly complete TME, respectively; P = 0.599). The resection margins, number of harvested lymph nodes, morbidity, and bowel function recovery also were not significantly different. On analyzing quality of life, scores of the European Organization for Research and Treatment of Cancer Quality of Life (EORTC QLQ C30) and EORTC QLQ CR38 were similar in the 2 groups, but in the EORTC QLQ CR 38 questionnaire, sexual function 12 months postoperatively was better in the robot-assisted group than in the laparoscopic group (P = 0.03). Robot-assisted surgery in rectal cancer showed TME quality comparable with that of laparoscopic surgery, and it demonstrated similar postoperative morbidity, bowel function recovery, and quality of life.

Surgical outcomes of robotic-assisted surgical staging for endometrial cancer are equivalent to traditional laparoscopic staging at a minimally invasive surgical center

PubMed Central

Cardenas-Goicoechea, Joel; Adams, Sarah; Bhat, Suneel B.; Randall, Thomas C.

2010-01-01

Objective To compare peri- and post-operative complications and outcomes of robotic-assisted surgical staging with traditional laparoscopic surgical staging for women with endometrial cancer. Methods A retrospective chart review of cases of women undergoing minimally invasive total hysterectomy and pelvic and para-aortic lymphadenectomy by a robotic-assisted approach or traditional laparoscopic approach was conducted. Major intraoperative complications, including vascular injury, enterotomy, cystotomy, or conversion to laparotomy, were measured. Secondary outcomes including operative time, blood loss, transfusion rate, number of lymph nodes retrieved, and the length of hospitalization were also measured. Results 275 cases were identified–102 patients with robotic-assisted staging and 173 patients with traditional laparoscopic staging. There was no significant difference in the rate of major complications between groups (p=0.13). The mean operative time was longer in cases of robotic-assisted staging (237 min vs. 178 min, p<0.0001); however, blood loss was significantly lower (109 ml vs. 187 ml, p<0.0001). The mean number of lymph nodes retrieved were similar between groups (p=0.32). There were no significant differences in the time to discharge, re-admission, or re-operation rates between the two groups. Conclusion Robotic-assisted surgery is an acceptable alternative to laparoscopy for minimally invasive staging of endometrial cancer. In addition to the improved ease of operation, visualization, and range of motion of the robotic instruments, robotic surgery results in a lower mean blood loss, although longer operative time. More data are needed to determine if the rates of urinary tract injuries and other surgical complications can be reduced with the use of robotic surgery. PMID:20144471

Our Experiences with Robot-Assisted Laparoscopic Radical Cystectomy: Orthotopic Neobladder by the Suprapubic Incision Method

PubMed Central

Cho, Byung Chul; Jung, Ha Bum; Cho, Sung Tae; Kim, Ki Kyung; Han, Jun Hyun; Lee, Yong Seong

2012-01-01

Purpose To report our technique for and experience with robot-assisted laparoscopic radical cystectomy (RARC) with orthotopic neobladder (ON) formation in a cohort of bladder cancer patients. Materials and Methods Between December 2007 and December 2011, a total of 35 patients underwent RARC. The patients' mean age was 63.3 years and their mean body mass index was 23.7 kg/m2. Thirty patients had a clinical stage of T2 or higher. Postoperative mean follow-up duration was 25.5 months. In 5 patients, a 4-cm midline infraumbilical skin incision was made for an ileal conduit (IC) and the stoma formation was similar to the open procedure. In 30 patients undergoing the ON procedure, the skin for specimen removal and extracorporeal enterocystoplasty was incised infraumbilically in the early 5 cases with redocking (ON-I) and suprapubically in the latter 25 cases without redocking (ON-S). Results The mean operative times of the IC, ON-I, and ON-S groups were 442.5, 646.0, and 531.3 minutes, respectively (p=0.001). Mean console and lymph node dissection time were not significantly different between the groups. Mean urinary diversion times in each group were 68.8, 125.0, and 118.8 minutes, respectively (p=0.001). In the comparison between the ON-I and ON-S group, only operative time was significant. Four patients required a blood transfusion. We had no cases of intraabdominal organ injury or open conversion. Thiry-three patients (94.2%) had a pathologic stage of T2 or higher. Two patients (5.7%) had lymph node-positive disease. Postoperative complications included ileus (n=4), stricture in the uretero-ileal junction (n=2), and vesicovaginal fistula (n=1). Conclusions Our robotic neobladder-suprapubic incision without redocking procedure is easier and more rapid than that of infraumbilical incision with redocking. PMID:23185668

The Curie–Da Vinci Connection: 5-Years' Experience With Laparoscopic (Robot-Assisted) Implantation for High-Dose-Rate Brachytherapy of Solitary T2 Bladder Tumors

DOE Office of Scientific and Technical Information (OSTI.GOV)

Steen-Banasik, Elzbieta M. van der, E-mail: E.vanderSteen-Banasik@radiotherapiegroep.nl; Smits, Geert A.H.J.; Oosterveld, Bernard J.

Purpose: To report experience and early results of laparoscopic implantation for interstitial brachytherapy (BT) of solitary bladder tumors and the feasibility of a high-dose-rate (HDR) schedule. Methods and Materials: From December 2009 to April 2015, 57 patients with a T2 solitary bladder tumor were treated in Arnhem with transurethral bladder resection followed by external beam irradiation, applied to the bladder and regional iliac lymph nodes, 40 Gy in 20 fractions, 5 fractions per week, and within 1 week interstitial HDR BT, in selected cases combined with partial cystectomy and lymph node dissection. The BT catheters were placed via a transabdominal approach withmore » robotic assistance from a Da Vinci robot after a successful initial experience with a nonrobotic laparoscopic approach. The fraction schedule for HDR was 10 fractions of 2.5 Gy, 3 fractions per day. This was calculated to be equivalent to a reference low-dose-rate schedule of 30 Gy in 60 hours. Data for oncologic outcomes and toxicity (Common Toxicity Criteria version 4) were prospectively collected. Results: These modifications resulted in an average postoperative hospitalization of 6 days, minimal blood loss, and no wound healing problems. Two patients had severe acute toxicity: 1 pulmonary embolism grade 4 and 1 cardiac death. Late toxicity was mild (n=2 urogenital grade 3 toxicity). The median follow-up was 2 years. Using cumulative incidence competing risk analysis, the 2-year overall, disease-free, and disease-specific survival and local control rates were 59%, 71%, 87%, and 82%, respectively. Conclusions: The benefits of minimally invasive surgery for implantation of BT catheters and the feasibility of HDR BT in bladder cancer are documented. The patient outcome and adverse events are comparable to the best results published for a bladder-sparing approach.« less

Transoral videolaryngoscopic surgery for papillary carcinoma arising in lingual thyroid.

PubMed

Mogi, Chisato; Shinomiya, Hirotaka; Fujii, Natsumi; Tsuruta, Tomoyuki; Morita, Naruhiko; Furukawa, Tatsuya; Teshima, Masanori; Kanzawa, Maki; Hirokawa, Mitsuyoshi; Otsuki, Naoki; Nibu, Ken-Ichi

2018-05-15

Carcinoma arising in lingual thyroid is an extremely rare entity accounting for only 1% of all reported ectopic thyroids. Here, we report a case of carcinoma arising in lingual thyroid, which has been successfully managed by transoral resection and bilateral neck dissections. A lingual mass 4-cm in diameter with calcification was incidentally detected by computed tomography at medical check-up. No thyroid tissue was observed in normal position. Ultrasound examination showed bilateral multiple lymphadenopathies. Fine needle aspiration biopsy from lymph node in his right neck was diagnosed as Class III and thyroglobulin level of the specimen was 459ng/ml. Due to the difficulty in performing FNA of the lingual masses, right neck dissection was performed in advance for diagnostic purpose. Pathological examination showed existence of large and small follicular thyroid tissues in several lymph nodes, suggesting lymph node metastasis from thyroid carcinoma. Two months after the initial surgery, video-assisted transoral resection of lingual thyroid with simultaneous left neck dissection was performed. Postoperative course was uneventful. Papillary carcinoma was found in the lingual thyroid and thyroid tissues were also found in left cervical lymph nodes. Video-assisted transoral resection was useful for the treatment of thyroid cancer arising in lingual thyroid. Copyright © 2018 Elsevier B.V. All rights reserved.

Use of robotics in colon and rectal surgery.

PubMed

Pucci, Michael J; Beekley, Alec C

2013-03-01

The pace of innovation in the field of surgery continues to accelerate. As new technologies are developed in combination with industry and clinicians, specialized patient care improves. In the field of colon and rectal surgery, robotic systems offer clinicians many alternative ways to care for patients. From having the ability to round remotely to improved visualization and dissection in the operating room, robotic assistance can greatly benefit clinical outcomes. Although the field of robotics in surgery is still in its infancy, many groups are actively investigating technologies that will assist clinicians in caring for their patients. As these technologies evolve, surgeons will continue to find new and innovative ways to utilize the systems for improved patient care and comfort.

Feasibility and optimal dosage of indocyanine green fluorescence for sentinel lymph node detection using robotic single-site instrumentation: preclinical study.

PubMed

Levinson, Kimberly L; Mahdi, Haider; Escobar, Pedro F

2013-01-01

The present study was performed to determine the optimal dosage of indocyanine green (ICG) to accurately differentiate the sentinel node from surrounding tissue and then to test this dosage using novel single-port robotic instrumentation. The study was performed in healthy female pigs. After induction of anesthesia, all pigs underwent exploratory laparotomy, dissection of the bladder, and colpotomy to reveal the cervical os. With use of a 21-gauge needle, 0.5 mL normal saline solution was injected at the 3- and 9-o'clock positions as control. Four concentrations of ICG were constituted for doses of 1000, 500, 250, and 175 μg per 0.5 mL. ICG was then injected at the 3- and 9-o'clock positions on the cervix. The SPY camera was used to track ICG into the sentinel nodes and to quantify the intensity of light emitted. SPY technology uses an intensity scale of 1 to 256; this scale was used to determine the difference in intensity between the sentinel node and surrounding tissues. The optimal dosage was tested using single-port robotic instrumentation with the same injection techniques. A sentinel node was identified at all doses except 175 μg, at which ICG stayed in the cervix and vasculature only. For both the 500- and 250-μg doses, the sentinel node was identified before reaching maximum intensity. At maximum intensity, the difference between the surrounding tissue and the node was 207 (251 vs 44) for the 500-μg dose and 159 (251 vs 92) for the 250-μg dose. Sentinel lymph node (SLN) biopsy was successfully performed using single-port robotic technology with both the 250- and 500-μg doses. For SLN detection, the dose of ICG is related to the ability to differentiate the sentinel node from the surrounding tissue. An ICG dose of 250 to 500 μg enables identification of a SLN with more distinction from the surrounding tissues, and this procedure is feasible using single-port robotics instrumentation. Copyright © 2013 AAGL. Published by Elsevier Inc. All rights reserved.

Comparison of long-term results between laparoscopy-assisted gastrectomy and open gastrectomy with D2 lymph node dissection for advanced gastric cancer.

PubMed

Hamabe, Atsushi; Omori, Takeshi; Tanaka, Koji; Nishida, Toshirou

2012-06-01

Laparoscopy-assisted gastrectomy (LAG) has been established as a low-invasive surgery for early gastric cancer. However, it remains unknown whether it is applicable also for advanced gastric cancer, mainly because the long-term results of LAG with D2 lymph node dissection for advanced gastric cancer have not been well validated compared with open gastrectomy (OG). A retrospective cohort study was performed to compare LAG and OG with D2 lymph node dissection. For this study, 167 patients (66 LAG and 101 OG patients) who underwent gastrectomy with D2 lymph node dissection for advanced gastric cancer were reviewed. Recurrence-free survival and overall survival time were estimated using Kaplan-Meier curves. Stratified log-rank statistical evaluation was used to compare the difference between the LAG and OG groups stratified by histologic type, pathologic T status, N status, and postoperative adjuvant chemotherapy. The adjusted Cox proportional hazards regression models were used to calculate the hazard ratios (HRs) of LAG. The 5-year recurrence-free survival rate was 89.6% in the LAG group and 75.8% in the OG group (nonsignificant difference; stratified log-rank statistic, 3.11; P = 0.0777). The adjusted HR of recurrence for LAG compared with OG was 0.389 [95% confidence interval (CI) 0.131-1.151]. The 5-year overall survival rate was 94.4% in the LAG group and 78.5% in the OG group (nonsignificant difference; stratified log-rank statistic, 0.4817; P = 0.4877). The adjusted HR of death for LAG compared with OG was 0.633 (95% CI 0.172-2.325). The findings show that LAG with D2 lymph node dissection is acceptable in terms of long-term results for advanced gastric cancer cases and may be applicable for advanced gastric cancer treatment.

Pelvic lymphadenectomy during robot-assisted radical prostatectomy: Assessing nodal yield, perioperative outcomes, and complications.

PubMed

Zorn, Kevin C; Katz, Mark H; Bernstein, Andrew; Shikanov, Sergey A; Brendler, Charles B; Zagaja, Gregory P; Shalhav, Arieh L

2009-08-01

To describe our pelvic lymphadenectomy (PLND) technique during robot-assisted radical prostatectomy and to evaluate the nodal yield and perioperative outcomes. PLND is commonly performed with radical prostatectomy for localized prostate cancer. Because of the limitations of the robotic arm pitch in accessing the pelvic sidewall and undersurface of the iliac bifurcation, uro-oncologists have questioned the adequacy of robotic PLND. PLND was routinely performed on men with higher risk preoperative prostate cancer parameters (ie, prostrate-specific antigen >10 ng/mL, primary Gleason score > or =4, or clinical Stage T2b or greater). The outcomes of robot-assisted radical prostatectomy with bilateral, standard template PLND (group 1; n = 296 [26%]) were compared with those of a cohort of 859 robot-assisted radical prostatectomy patients (74%) without PLND (group 2). We also compared these data with those from a single-surgeon experience of open, standard-template PLND for retropubic radical prostatectomy. The mean number of lymph nodes removed was 12.5 (interquartile range 7-16). The mean operative time (224 vs 216 minutes; P = .09), estimated blood loss (206 vs 229 mL; P = .14), and hospital stay (1.32 vs 1.24 days; P = .46) were comparable between the 2 groups. The rate of intraoperative complications (1% vs 1.5%; P = .2), overall postoperative complications (9% vs 7%; P = .8), and lymphocele formation (2% vs 0%; P = .9) were not significantly different. The review of our open series and the historically published open standard-template PLND series revealed a mean yield of 15 and a range of 6.7-15 lymph nodes removed, respectively. Our data support the feasibility and low complication rate of robotic standard-template PLND with lymph node yields comparable to those with open PLND. Considering the low morbidity of PLND in experienced hands, coupled with the potential of preoperative undergrading and understaging and the therapeutic benefit to patients with micrometastatic disease, an increase in overall standard-template PLND use should be considered.

Use of Robotics in Colon and Rectal Surgery

PubMed Central

Pucci, Michael J.; Beekley, Alec C.

2013-01-01

The pace of innovation in the field of surgery continues to accelerate. As new technologies are developed in combination with industry and clinicians, specialized patient care improves. In the field of colon and rectal surgery, robotic systems offer clinicians many alternative ways to care for patients. From having the ability to round remotely to improved visualization and dissection in the operating room, robotic assistance can greatly benefit clinical outcomes. Although the field of robotics in surgery is still in its infancy, many groups are actively investigating technologies that will assist clinicians in caring for their patients. As these technologies evolve, surgeons will continue to find new and innovative ways to utilize the systems for improved patient care and comfort. PMID:24436647

Robot-Assisted Mckeown Esophagectomy is Feasible After Neoadjuvant Chemoradiation. Our Initial Experience.

PubMed

Goel, Ashish; Shah, Swati H; Selvakumar, Veda Padma Priya; Garg, Shubha; Kumar, Kapil

2018-02-01

Neoadjuvant chemoradiation has become the standard of care for esophageal cancer, especially for middle third esophageal lesions and those with squamous histology. Although more and more thoracic surgeons and surgical oncologists have now shifted to video-assisted and robot-assisted thoracoscopic esophagectomy; there is still limited experience for the use of minimal-assisted approaches in patients undergoing surgery after neoadjuvant chemoradiation. Most surgeons have concerns of feasibility, safety, and oncological outcomes as well as issues related to difficult learning curve in adopting robotic esophagectomy in patients after chemoradiation. We present our initial experience of Robot-Assisted Mckeown Esophagectomy in 27 patients after neoadjuvant chemoradiation, from May 2013 to October 2014. All patients underwent neoadjuvant chemoradiation to a dose of 50.4 Gy/25Fr with concurrent weekly cisplatin, followed by reassessment with clinical examination and repeat FDG PET/CT 6 weeks after completion of chemoradiation. Patients with progressive disease underwent palliative chemotherapy while patients with either partial or significant response to chemoradiation underwent Robot-Assisted Mckeown Esophagectomy with esophageal replacement by gastric conduit and esophagogastric anastomosis in the left neck. Out of 27 patients, 92.5 % patients had stage cT3/T4 tumours and node-positive disease in 48.1 % on imaging. Most patients were middle thoracic esophageal cancers (23/27), with squamous histology in all except for one. All patients received neoadjuvant chemoradiation and subsequently underwent Robot Assisted Mckeown Esophagectomy. The average time for robot docking, thoracic mobilization and total surgical procedure was 13.2, 108.4 and 342.7 min, respectively. The procedure was well tolerated by all patients with only one case of peri-operative mortality. Average ICU stay was 6.35 days (range 3-9 days). R0 resection rate of 96.3 % and average lymph node yield of 18 could be achieved. Pathological node negativity rate (pN0) and complete response (pCR) were 66.6 and 44.4 %, respectively. In the initial cases, four patients had to be converted to open due technical reasons or intraoperative complications. The present study, with shorter operative times, similar ICU stay, overall low morbidity, and mortality and optimal oncological outcomes suggest that robot-assisted thoracic mobilization of esophagus in patients with prior chemoradiation is feasible and safe with acceptable oncological outcomes. It has a shorter learning curve and hence allows for a transthoracic minimally invasive transthoracic esophagectomy to more and more patients, otherwise unfit for conventional approach.

Robotic-assisted laparoscopic radical nephrectomy using the Da Vinci Si system: how to improve surgeon autonomy. Our step-by-step technique.

PubMed

Davila, Hugo H; Storey, Raul E; Rose, Marc C

2016-09-01

Herein, we describe several steps to improve surgeon autonomy during a Left Robotic-Assisted Laparoscopic Radical Nephrectomy (RALRN), using the Da Vinci Si system. Our kidney cancer program is based on 2 community hospitals. We use the Da Vinci Si system. Access is obtained with the following trocars: Two 8 mm robotic, one 8 mm robotic, bariatric length (arm 3), 15 mm for the assistant and 12 mm for the camera. We use curved monopolar scissors in robotic arm 1, Bipolar Maryland in arm 2, Prograsp Forceps in arm 3, and we alternate throughout the surgery with EndoWrist clip appliers and the vessel sealer. Here, we described three steps and the use of 3 robotic instruments to improve surgeon autonomy. Step 1: the lower pole of the kidney was dissected and this was retracted upwards and laterally. This maneuver was performed using the 3rd robotic arm with the Prograsp Forceps. Step 2: the monopolar scissors was replaced (robotic arm 1) with the robotic EndoWrist clip applier, 10 mm Hem-o-Lok. The renal artery and vein were controlled and transected by the main surgeon. Step 3: the superior, posterolateral dissection and all bleeders were carefully coagulated by the surgeon with the EndoWrist one vessel sealer. We have now performed 15 RALRN following these steps. Our results were: blood loss 300 cc, console time 140 min, operating room time 200 min, anesthesia time 180 min, hospital stay 2.5 days, 1 incisional hernia, pathology: (13) RCC clear cell, (1) chromophobe and (1) papillary type 1. Tumor Stage: (5) T1b, (8) T2a, (2) T2b. We provide a concise, step-by-step technique for radical nephrectomy (RN) using the Da Vinci Si robotic system that may provide more autonomy to the surgeon, while maintaining surgical outcome equivalent to standard laparoscopic RN.

Advanced Applications of Robotics in Digestive Surgery

PubMed Central

Patriti, Alberto; Addeo, Pietro; Buchs, Nicolas; Casciola, Luciano; Morel, Philippe

2011-01-01

Laparoscopy is widely recognized as feasible and safe approach to many oncologic and benign digestive conditions and is associated with an improved early outcome. Robotic surgery promises to overcome intrinsic limitations of laparoscopic surgery by a three-dimensional view and wristed instruments widening indications for a minimally invasive approach. To date, the more interesting applications of robotic surgery are those operations restricted to one abdominal quadrant and requiring a fine dissection and digestive reconstruction. While robot-assisted rectal and gastric surgery are becoming well-accepted options among the surgical community, applications of robotics in hepato-biliary and pancreatic surgery are still debated. PMID:23905029

Robotic salvage lymph node dissection for nodal-only recurrences after radical prostatectomy: Perioperative and early oncological outcomes.

PubMed

Linxweiler, Johannes; Saar, Matthias; Al-Kailani, Zaid; Janssen, Martin; Ezziddin, Samer; Stöckle, Michael; Siemer, Stefan; Ohlmann, Carsten-Henning

2018-06-01

Salvage lymph node dissection (sLND) - performed open or minimally-invasive - is a treatment modality that can be offered to patients with nodal recurrence after radical prostatectomy (RP), especially in times where modern imaging methods like choline- or PSMA-PET/CT are available. Yet, there are only very limited data on the safety and oncological effectiveness of robotic sLND. We retrospectively identified patients who underwent robotic sLND at our institution between 2013 and 2017 for nodal recurrence after RP, which had been diagnosed either by 18 F-choline- or 68 Ga-PSMA-PET/CT. We analyzed perioperative data and early oncological outcomes with a focus on the comparison of patients with preoperative choline- vs. those with preoperative PSMA-PET/CT. We identified 36 patients who underwent robotic sLND at a median time of 45.3 months [range 3.1;228.6] after RP, with nodal recurrences detected in 25 patients by PSMA- and in 11 by choline-PET/CT. Median preoperative PSA, operation time and blood loss were 1.98 ng/ml [range 0.09;35.15], 129.5 min [range 65;202] and 50 ml [range 0;400], respectively. No high-grade complications occurred. A median number of 6.5 [range 1;25] lymph nodes were removed with a median of 1 [range 0;9] tumor-occupied node. None of the patients received any adjuvant treatment. Median postoperative PSA-change was -57% [range -100; +58] in the PSMA- and +10% [range -91; +95] in the choline-group (p = 0.015). 44% of patients in the PSMA- and 18% of patients in the choline-group experienced complete biochemical response (cBCR; PSA <0.2 ng/ml). Median time from sLND to the initiation of further therapy was 12 months [range 2;21.5] in the PSMA-group and 4.7 months [range 2.2;18.9] in the choline-group (p = 0.001). This is the hitherto largest series on robotic sLND for nodal recurrence after RP. Robotic sLND is a feasible therapeutic option with low morbidity, which can at least delay the initiation of further therapy - in some patients up to several years. However, the extend of sLND has to be standardized and randomized trials are needed to finally define the oncological effectiveness of this approach. Copyright © 2018 Elsevier Ltd. All rights reserved.

Sentinel Lymph Node Dissection to Select Clinically Node-negative Prostate Cancer Patients for Pelvic Radiation Therapy: Effect on Biochemical Recurrence and Systemic Progression

DOE Office of Scientific and Technical Information (OSTI.GOV)

Grivas, Nikolaos, E-mail: n.grivas@nki.nl; Wit, Esther; Pos, Floris

Purpose: To assess the efficacy of robotic-assisted laparoscopic sentinel lymph node (SLN) dissection (SLND) to select those patients with prostate cancer (PCa) who would benefit from additional pelvic external beam radiation therapy and long-term androgen deprivation therapy (ADT). Methods and Materials: Radioisotope-guided SLND was performed in 224 clinically node-negative patients scheduled to undergo external beam radiation therapy. Patients with histologically positive SLNs (pN1) were also offered radiation therapy to the pelvic lymph nodes, combined with 3 years of ADT. Biochemical recurrence (BCR), overall survival, and metastasis-free (including pelvic and nonregional lymph nodes) survival (MFS) rates were retrospectively calculated. The Briganti andmore » Kattan nomogram predictions were compared with the observed pN status and BCR. Results: The median prostate-specific antigen (PSA) value was 15.4 ng/mL (interquartile range [IQR] 8-29). A total number of 834 SLNs (median 3 per patient; IQR 2-5) were removed. Nodal metastases were diagnosed in 42% of the patients, with 150 SLNs affected (median 1; IQR 1-2). The 5-year BCR-free and MFS rates for pN0 patients were 67.9% and 87.8%, respectively. The corresponding values for pN1 patients were 43% and 66.6%. The PSA level and number of removed SLNs were independent predictors of BCR and MFS, and pN status was an additional independent predictor of BCR. The 5-year overall survival rate was 97.6% and correlated only with pN status. The predictive accuracy of the Briganti nomogram was 0.665. Patients in the higher quartiles of Kattan nomogram prediction of BCR had better than expected outcomes. The complication rate from SLND was 8.9%. Conclusions: For radioisotope-guided SLND, the high staging accuracy is accompanied by low morbidity. The better than expected outcomes observed in the lower quartiles of BCR prediction suggest a role for SLN biopsy as a potential selection tool for the addition of pelvic radiation therapy and ADT intensification in pN1 patients.« less

Navigating the pathway to robotic competency in general thoracic surgery.

PubMed

Seder, Christopher W; Cassivi, Stephen D; Wigle, Dennis A

2013-01-01

Although robotic technology has addressed many of the limitations of traditional videoscopic surgery, robotic surgery has not gained widespread acceptance in the general thoracic community. We report our initial robotic surgery experience and propose a structured, competency-based pathway for the development of robotic skills. Between December 2008 and February 2012, a total of 79 robot-assisted pulmonary, mediastinal, benign esophageal, or diaphragmatic procedures were performed. Data on patient characteristics and perioperative outcomes were retrospectively collected and analyzed. During the study period, one surgeon and three residents participated in a triphasic, competency-based pathway designed to teach robotic skills. The pathway consisted of individual preclinical learning followed by mentored preclinical exercises and progressive clinical responsibility. The robot-assisted procedures performed included lung resection (n = 38), mediastinal mass resection (n = 19), hiatal or paraesophageal hernia repair (n = 12), and Heller myotomy (n = 7), among others (n = 3). There were no perioperative mortalities, with a 20% complication rate and a 3% readmission rate. Conversion to a thoracoscopic or open approach was required in eight pulmonary resections to facilitate dissection (six) or to control hemorrhage (two). Fewer major perioperative complications were observed in the later half of the experience. All residents who participated in the thoracic surgery robotic pathway perform robot-assisted procedures as part of their clinical practice. Robot-assisted thoracic surgery can be safely learned when skill acquisition is guided by a structured, competency-based pathway.

The Clinical Application of Mastectomy With Single Incision Followed by Immediate Laparoscopic-Assisted Breast Reconstruction With Latissimus Dorsi Muscle Flap.

PubMed

Yuan, Huozhong; Xie, Donghua; Xiao, Xigang; Huang, Xingwei

2017-08-01

To explore the clinical application of mastectomy with single incision followed by immediate laparoscopic-assisted breast reconstruction with latissimus dorsi muscle flap. Fifteen women with primary early breast cancer, 3 women with breast ductal carcinoma in situ, and 7 women with severe plasma cell mastitis were treated with partial mastectomy or total mastectomy, sentinel lymph node biopsy, or axillary lymph node dissection through a breast lateral transverse incision. Subsequent breast reconstruction with latissimus dorsi muscle flap was assisted by laparoscopy. The patient's position, time used in dissecting latissimus dorsi muscle flap, size of latissimus dorsi muscle flap, postoperative complications, and the cosmetic results after reconstruction were assessed. All the operations were well done through the breast lateral transverse incision and assistance of laparoscopy. The patient's position was changed only once during the operation. It took 1.5 to 2 hours to dissect latissimus dorsi muscle flap. The sizes of the latissimus dorsi muscle flap were 5 to 8 × 12 to 16 cm. There were no serious postoperative complications noted. The patients were satisfied with the appearance of the breasts and the small surgical scar. The surgical approach introduced is minimally invasive with concealed scar and outstanding cosmetic results. It is worth promoting in clinical application.

Stage-directed individualized therapy in esophageal cancer.

PubMed

Goense, Lucas; van Rossum, Peter S N; Kandioler, Daniela; Ruurda, Jelle P; Goh, Khean-Lee; Luyer, Misha D; Krasna, Mark J; van Hillegersberg, Richard

2016-10-01

Esophageal cancer is the eighth most common cancer worldwide, and the incidence of esophageal carcinoma is rapidly increasing. With the advent of new staging and treatment techniques, esophageal cancer can now be managed through various strategies. A good understanding of the advances and limitations of new staging techniques and how these can guide in individualizing treatment is important to improve outcomes for esophageal cancer patients. This paper outlines the recent progress in staging and treatment of esophageal cancer, with particularly attention to endoscopic techniques for early-stage esophageal cancer, multimodality treatment for locally advanced esophageal cancer, assessment of response to neoadjuvant treatment, and the role of cervical lymph node dissection. Furthermore, advances in robot-assisted surgical techniques and postoperative recovery protocols that may further improve outcomes after esophagectomy are discussed. © 2016 The Authors. Annals of the New York Academy of Sciences published by Wiley Periodicals Inc. on behalf of The New York Academy of Sciences.

Robot-Assisted Transoral Odontoidectomy : Experiment in New Minimally Invasive Technology, a Cadaveric Study

PubMed Central

Yang, Moon Sul; Yoon, Tae Ho; Yoon, Do Heum; Kim, Keung Nyun; Pennant, William

2011-01-01

Objective In the field of spinal surgery, a few laboratory results or clinical cases about robotic spinal surgery have been reported. In vivo trials and development of related surgical instruments for spinal surgery are required before its clinical application. We investigated the use of the da Vinci® Surgical System in spinal surgery at the craniovertebral junction in a human cadaver to demonstrate the efficacy and pitfalls of robotic surgery. Methods Dissection of pharyngeal wall to the exposure of C1 and odontoid process was performed with full robotic procedure. Although assistance of another surgeon was necessary for drilling and removal of odontoid process due to the lack of appropriate end-effectors, successful robotic procedures for dural sutures and exposing spinal cord proved its safety and dexterity. Results Robot-assisted odontoidectomy was successfully performed in a human cadaver using the da Vinci® Surgical System with few robotic arm collisions and minimal soft tissue damages. Da Vinci® Surgical System manifested more dexterous movement than human hands in the deep and narrow oral cavity. Furthermore, sutures with robotic procedure in the oral cavity demonstrated the advantage over conventional procedure. Conclusion Presenting cadaveric study proved the probability of robot-assisted transoral approach. However, the development of robotic instruments specific to spinal surgery must first precede its clinical application. PMID:21607188

Total intracorporeal robot-assisted laparoscopic ileal conduit (Bricker) urinary diversion: technique and outcomes.

PubMed

Rehman, Jamil; Sangalli, Mattia N; Guru, Khurshid; de Naeyer, Geert; Schatteman, Peter; Carpentier, Paul; Mottrie, Alexander

2011-02-01

Several recent preliminary reports have demonstrated that Robot-Assisted Cystectomy with total intracorporeal Ileal Conduit (RACIC) is a feasible option over the open technique. We report our stepwise surgical procedure of robotic total intracorporeal ileal conduit urinary diversion, technical consideration, development, refinements and initial experience. Only the ileal conduit urinary diversion is described with no emphasis on the cystectomy's steps. Between February 2008 and September 2009, nine patients underwent RACIC for muscle invasive transitional cell carcinoma (TCC). The entire procedure, including radical cystoprostatectomy, extended pelvic node dissection (ePLND), ileal conduit urinary diversion (Bricker) including isolation of the ileal loop (20 cm ileal segment) 15 cm away from the ileocecal junction, restoration of bowel continuity with stapled side-to-side ileo-ileal anastomosis, retroperitoneal transfer of the left ureter to the right side, and bilateral stented (8 F feeding tube) ileo-ureteral anastomoses in a Wallace faction were all performed exclusively intracorporeally using the da Vinci Si surgical robot and finally the conduit stoma was fashioned. The RACIC was technically successful in all nine patients (three females and six males. Mean age 74.1; 57 to 87) without open conversion. The mean operative time including extended pelvic lymphadenectomy and urinary diversion was 346.2 minutes (210 to 480). Mean operative time of diversion is 72 minutes (52-113) mean estimated blood loss 258 mL (200 to 500) and the median hospital stay were 14 days (10 to 27). In all three female patients, the specimen was extracted through the vagina. There were no intraoperative complications and only one major postoperative complication: one postoperative iatrogenous necrosis of the ileal conduit caused by uncareful retraction of the organ bag and thereby probably injuring the conduit pedicle, as the ileal conduit was well vascularised at the end of the operation, requiring an open revision (in male patient extracted through the suprapubic incision). A clear liquid diet was started on the third postoperative day. All patients returned to normal activity within 2 weeks (from date of surgery). Postoperative renal function was normal with mean postoperative creatine 0.99 mg/dL) and excretory urography revealed unobstructed upper tracts in all cases. Robot-assisted radical cystoprostatectomy with intracorporeal ileal conduit urinary diversion for the treatment of high risk or invasive bladder cancer with urinary diversion is technically feasible. The robotic system aids in performing a meticulous dissection and all operative steps of the open procedure are replicated precisely while adhering to the sound oncologic principles of traditional radical cystectomy. Robotics brings an unprecedented control of surgical instruments, shorten the learning curve, and allow open surgeons to apply more easily their technical skill in a minimal invasive fashion. Robotic cystectomy with total intracorporeal ileal conduit urinary diversion offers operative and perioperative benefits and functional outcome. In our hands results comparable to open experience with further reduced perioperative morbidity, early recovery, resumption of normal activities, excellent cosmesis and increased quality of life (QOL). In addition, minimal blood loss, fluid shifts, and electrolyte loss considerably reduce systemic and cardiovascular stress in these older groups of patients.

A Novel Telemanipulated Robotic Assistant for Surgical Endoscopy: Preclinical Application to ESD.

PubMed

Zorn, Lucile; Nageotte, Florent; Zanne, Philippe; Legner, Andras; Dallemagne, Bernard; Marescaux, Jacques; de Mathelin, Michel

2018-04-01

Minimally invasive surgical interventions in the gastrointestinal tract, such as endoscopic submucosal dissection (ESD), are very difficult for surgeons when performed with standard flexible endoscopes. Robotic flexible systems have been identified as a solution to improve manipulation. However, only a few such systems have been brought to preclinical trials as of now. As a result, novel robotic tools are required. We developed a telemanipulated robotic device, called STRAS, which aims to assist surgeons during intraluminal surgical endoscopy. This is a modular system, based on a flexible endoscope and flexible instruments, which provides 10 degrees of freedom (DoFs). The modularity allows the user to easily set up the robot and to navigate toward the operating area. The robot can then be teleoperated using master interfaces specifically designed to intuitively control all available DoFs. STRAS capabilities have been tested in laboratory conditions and during preclinical experiments. We report 12 colorectal ESDs performed in pigs, in which large lesions were successfully removed. Dissection speeds are compared with those obtained in similar conditions with the manual Anubiscope platform from Karl Storz. We show significant improvements ( ). These experiments show that STRAS (v2) provides sufficient DoFs, workspace, and force to perform ESD, that it allows a single surgeon to perform all the surgical tasks and those performances are improved with respect to manual systems. The concepts developed for STRAS are validated and could bring new tools for surgeons to improve comfort, ease, and performances for intraluminal surgical endoscopy.

A Novel Approach for Apical Dissection During Robot-assisted Radical Prostatectomy: The "Collar" Technique.

PubMed

Bianchi, Lorenzo; Turri, Filippo Maria; Larcher, Alessandro; De Groote, Ruben; De Bruyne, Peter; De Coninck, Vincent; Goossens, Marijn; D'Hondt, Frederiek; De Naeyer, Geert; Schatteman, Peter; Mottrie, Alexandre

2018-02-02

Apical dissection in robot-assisted radical prostatectomy (RARP) affects not only cancer control, but also continence recovery. To describe a novel approach for apical dissection, the collar technique, to reduce apical positive surgical margins (PSMs). A total of 189 consecutive patients (81 in the control group, 108 in the collar technique group) underwent RARP at a single center. rates of apical PSMs; secondary outcome: urinary continence. The urethral sphincter complex is incised 2-3mm distally to the apex, to stay farther from it and reduce PSMs; the underlying smooth muscle is exposed and incised closer to the apex to preserve the maximal length of the lissosphincter. Mann-Whitney U and chi-square tests compared median and proportions between the two groups, respectively. Univariate logistic regression tested the association between technique employed and risk of apical PSMs. Fourteen patients (7.4%) revealed apical PSMs (9.9% in the control group, 5.6% in the collar group; p=0.7). When the collar technique was used, significantly lower rates of apical PSMs occurred in pT2 disease (0% vs 7.1%; p=0.03). In case of apical tumor at preoperative magnetic resonance imaging (MRI; n=43), the collar technique determined significantly lower overall (9.7% vs 42%) and apical (3.2% vs 42%) PSMs (all p≤0.02). Continence recovery in the collar and control groups was similar. When preoperative MRI showed an apical tumor, the collar technique had a significantly lower risk of apical PSMs (odds ratio: 0.05, p=0.009). The collar technique reduces the rates of apical PSMs in case of apical tumor, preserving the length of the lissosphincter. We describe a novel approach for apical dissection during robot-assisted radical prostatectomy. Our technique reduces the rates of apical surgical margins in case of apical tumor at preoperative magnetic resonance imaging and leads to optimal continence recovery. Copyright © 2018 European Association of Urology. Published by Elsevier B.V. All rights reserved.

[Surgical Treatment of Small Pulmonary Nodules Under Video-assisted Thoracoscopy 
(A Report of 129 Cases)].

PubMed

Wang, Tong; Yan, Tiansheng; Wan, Feng; Ma, Shaohua; Wang, Keyi; Wang, Jingdi; Song, Jintao; He, Wei; Bai, Jie; Jin, Liang

2017-01-20

The development of image technology has led to increasing detection of pulmonary small nodules year by year, but the determination of their nature before operation is difficult. This clinical study aimed to investigate the necessity and feasibility of surgical resection of pulmonary small nodules through a minimally invasive approach and the operational manner of non-small cell lung cancer (NSCLC). The clinical data of 129 cases with pulmonary small nodule of 10 mm or less in diameter were retrospectively analyzed in our hospital from December 2013 to November 2016. Thin-section computed tomography (CT) was performed on all cases with 129 pulmonary small nodules. CT-guided hook-wire precise localization was performed on 21 cases. Lobectomy, wedge resection, and segmentectomy with lymph node dissection might be performed in patients according to physical condition. Results of the pathological examination of 37 solid pulmonary nodules (SPNs) revealed 3 primary squamous cell lung cancers, 3 invasive adenocarcinomas (IAs), 2 metastatic cancers, 2 small cell lung cancers (SCLCs), 16 hamartomas, and 12 nonspecific chronic inflammations. The results of pathological examination of 49 mixed ground glass opacities revealed 19 IAs, 6 micro invasive adenocarcinomas (MIAs), 4 adenocarcinomas in situ (AIS), 1 atypical adenomatous hyperplasia (AAH), 1 SCLC, and 18 nonspecific chronic inflammations. The results of pathological examination of 43 pure ground glass opacities revealed 19 AIS, 6 MIAs, 6 IA, 6 AAHs, and 6 nonspecific chronic inflammations. Wedge resection under video-assisted thoracoscopic surgery (VATS) was performed in patients with 52 benign pulmonary small nodules. Lobectomy and systematic lymph node dissection under VATS were performed in 33 patients with NSCLC. Segmentectomy with selective lymph node dissection, wedge resection, and selective lymph node dissection under VATS were performed in six patients with NSCLC. Two patients received secondary lobectomy and systematic lymph node dissection under VATS because of intraoperative frozen pathologic error that happened in six cases. Two cases of N2 lymph node metastasis were found in patients with SPN of IA. Positive surgical treatment should be taken on patients with persistent pulmonary small nodules, especially ground glass opacity, because they have a high rate of malignant lesions. During the perioperative period, surgeons should fully inform the patients and family members that error exist in frozen pathologic results to avoid medical disputes.

Clinical significance of the pattern of lymph node metastasis depending on the location of gastric cancer.

PubMed

Han, Ki Bin; Jang, You Jin; Kim, Jong Han; Park, Sung Soo; Park, Seong Heum; Kim, Seung Joo; Mok, Young Jae; Kim, Chong Suk

2011-06-01

When performing a laparoscopic assisted gastrectomy, a function-preserving gastrectomy is performed depending on the location of the primary gastric cancer. This study examined the incidence of lymph node metastasis by the lymph node station number by tumor location to determine the optimal extent of the lymph node dissection. The subjects consisted of 1,510 patients diagnosed with gastric cancer who underwent a gastrectomy between 1996 and 2005. The patients were divided into three groups: upper, middle and lower third, depending on the location of the primary tumor. The lymph node metastasis patterns were analyzed in the total and early gastric cancer patients. In all patients, lymph node station numbers 1, 2, 3, 7, 10 and 11 metastases were dominant in the cancer originating in the upper third, whereas station numbers 4, 5, 6 and 8 were dominant in the lower third. In early gastric cancer patients, the station number of lymph nodes with a metastasis did not show a significant difference in stage pT1a disease. On the other hand, a metastasis in lymph node station number 6 was dominant in stage pT1b disease that originated in the lower third of the stomach. When performing a laparoscopic-assisted gastrectomy for early gastric cancer, a limited lymphadenectomy is considered adequate during a function-preserving gastrectomy in mucosal (T1a) cancer. On the other hand, for submucosal (T1b) cancer, a number 6 node dissection should be performed when performing a pylorus preserving gastrectomy.

Starting a robotic program in general thoracic surgery: why, how, and lessons learned.

PubMed

Cerfolio, Robert J; Bryant, Ayesha S; Minnich, Douglas J

2011-06-01

We report our experience in starting a robotic program in thoracic surgery. We retrospectively reviewed our experience in starting a robotic program in general thoracic surgery on a consecutive series of patients. Between February 2009 and September 2010, 150 patients underwent robotic operations. Types of procedures were lobectomy in 62, thymectomy in 30, and benign esophageal procedures in 6. No thymectomy or esophageal procedures required conversion. One conversion was needed for suspected bleeding for a mediastinal mass. Twelve patients were converted for lobectomy (none for bleeding, 1 in the last 24). Median operative time for robotic thymectomy was 119 minutes, and median length of stay was 1 day. The median time for robotic lobectomy was 185 minutes, and median length of stay was 2 days. There were no operative deaths. Morbidity occurred in 23 patients (15%). All patients with cancer had R0 resections and resection of all visible mediastinal and hilar lymph nodes. Robotic surgery is safe and oncologically sound. It requires training of the entire operating room team. The learning curve is steep, involving port placement, availability of the proper instrumentation, use of the correct robotic arms, and proper patient positioning. The robot provides an ideal surgical approach for thymectomy and other mediastinal tumors. Its advantage over thoracoscopy for pulmonary resection is unproven; however, we believe complete thoracic lymph node dissection and teaching is easier. Importantly, defined credentialing for surgeons and cost analysis studies are needed. Copyright © 2011 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.

Utilization of sentinel lymph node biopsy for uterine cancer.

PubMed

Wright, Jason D; Cham, Stephanie; Chen, Ling; Burke, William M; Hou, June Y; Tergas, Ana I; Desai, Vrunda; Hu, Jim C; Ananth, Cande V; Neugut, Alfred I; Hershman, Dawn L

2017-06-01

To limit the potential short and long-term morbidity of lymphadenectomy, sentinel lymph node biopsy has been proposed for endometrial cancer. The principle of sentinel lymph node biopsy relies on removal of a small number of lymph nodes that are the first drainage basins from a tumor and thus the most likely to harbor tumor cells. While the procedure may reduce morbidity, efficacy data are limited and little is known about how commonly the procedure is performed. We examined the patterns and predictors of use of sentinel lymph node biopsy and outcomes of the procedure in women with endometrial cancer who underwent hysterectomy. We used the Perspective database to identify women with uterine cancer who underwent hysterectomy from 2011 through 2015. Billing and charge codes were used to classify women as having undergone lymphadenectomy, sentinel lymph node biopsy, or no nodal assessment. Multivariable models were used to examine clinical, demographic, and hospital characteristics with use of sentinel lymph node biopsy. Length of stay and cost were compared among the different methods of nodal assessment. Among 28,362 patients, 9327 (32.9%) did not undergo nodal assessment, 17,669 (62.3%) underwent lymphadenectomy, and 1366 (4.8%) underwent sentinel lymph node biopsy. Sentinel lymph node biopsy was performed in 1.3% (95% confidence interval, 1.0-1.6%) of abdominal hysterectomies, 3.4% (95% confidence interval, 2.7-4.1%) of laparoscopic hysterectomies, and 7.5% (95% confidence interval, 7.0-8.0%) of robotic-assisted hysterectomies. In a multivariable model, more recent year of surgery was associated with performance of sentinel lymph node biopsy. Compared to abdominal hysterectomy, those undergoing laparoscopic (adjusted risk ratio, 2.45; 95% confidence interval, 1.89-3.18) and robotic-assisted (adjusted risk ratio, 2.69; 95% confidence interval, 2.19-3.30) hysterectomy were more likely to undergo sentinel lymph node biopsy. Among women who underwent minimally invasive hysterectomy, length of stay and cost were lower for sentinel lymph node biopsy compared to lymphadenectomy. The use of sentinel lymph node biopsy for endometrial cancer increased from 2011 through 2015. The increased use was most notable in women who underwent a robotic-assisted hysterectomy. Copyright © 2017 Elsevier Inc. All rights reserved.

Robotic-assisted laparoscopic radical cystectomy: history, techniques and outcomes.

PubMed

Liss, Michael A; Kader, A Karim

2013-06-01

Robotic-assisted radical cystectomy (RARC) is a less invasive means of performing the radical cystectomy operation, which holds promise for improved patient morbidity. We review the history, technique and current literature pertaining to RARC and place the current results in context with the open procedure. All articles regarding RARC found in PubMed after January 2000 were examined. We selected articles that appeared in high-impact journals, had large patient population size (>80 patients), or were novel in technique or findings. We chose key laparoscopic articles to give reference to the history in transition to robotic radical cystectomy. In addition, we chose classic articles from open radical cystectomy to give reference regarding the newer robotic perioperative outcomes. Studies suggest that a 20-patient learning curve is needed to reach an operative time of 6.5 h, with 30 surgeries performed to reach lymph node counts in excess of 20 (International Robotic Cystectomy Consortium). The only randomized surgical trial comparing open and robotic techniques showed equivalent lymph node yield, which may be surgeon and volume dependent. Literature demonstrates lower estimated blood loss, transfusion rates, early return of bowel function and decreased complications in early small series. RARC and urinary diversion are still early in development and limited to centers with extensive robotic experience and volume, although adoption of the robotic approach is becoming more common. Early studies have shown promise to reduce complications with equivalent oncologic results.

[Robot-assisted minimally invasive lobectomy with systematic lymphadenectomy for lung cancer].

PubMed

Egberts, J-H; Schlemminger, M; Schafmayer, C; Dohrmann, P; Becker, T

2015-02-01

Lobectomy for lung cancer is the standard therapy for lung cancer in limited stages. The adoption of minimally invasive lobectomy (video-assisted thoracic surgery or VATS lobectomy) has increased worldwide since its first description more than 15 years ago. However, the VATS technique has a long learning curve and sometimes limitations in terms of precise preparation and presentability of the central structures of the lung hilus due to the limited mobility of the standard thoracoscopic instruments. By using a four-arm robotic platform (DaVinci®), not only the preparation of the hilus structures but also the central lymphadenectomy can be performed in a comfortable and safe way under a clear and precise view. Surgical treatment of locally limited lung cancer in the right lower lobe (squamous cell carcinoma). Robot-assisted, minimally invasive right lower lobectomy with systematic lymphadenectomy. Robot-assisted minimal invasive lobectomy is feasible with special regard to oncological and technical aspects. Especially the intrathoracic precise dissection of the tissue under a perfect view allow a comfortable and safe operation technique. Georg Thieme Verlag KG Stuttgart · New York.

Incidence and location of positive surgical margin among open, laparoscopic and robot-assisted radical prostatectomy in prostate cancer patients: a single institutional analysis.

PubMed

Koizumi, Atsushi; Narita, Shintaro; Nara, Taketoshi; Takayama, Koichiro; Kanda, Sohei; Numakura, Kazuyuki; Tsuruta, Hiroshi; Maeno, Atsushi; Huang, Mingguo; Saito, Mitsuru; Inoue, Takamitsu; Tsuchiya, Norihiko; Satoh, Shigeru; Nanjo, Hiroshi; Habuchi, Tomonori

2018-06-19

To evaluate the positive surgical margin rates and locations in radical prostatectomy among three surgical approaches, including open radical prostatectomy, laparoscopic radical prostatectomy and robot-assisted radical prostatectomy. We retrospectively reviewed clinical outcomes at our institution of 450 patients who received radical prostatectomy. Multiple surgeons were involved in the three approaches, and a single pathologist conducted the histopathological diagnoses. Positive surgical margin rates and locations among the three approaches were statistically assessed, and the risk factors of positive surgical margin were analyzed. This study included 127, 136 and 187 patients in the open radical prostatectomy, laparoscopic radical prostatectomy and robot-assisted radical prostatectomy groups, respectively. The positive surgical margin rates were 27.6% (open radical prostatectomy), 18.4% (laparoscopic radical prostatectomy) and 13.4% (robot-assisted radical prostatectomy). In propensity score-matched analyses, the positive surgical margin rate in the robot-assisted radical prostatectomy was significantly lower than that in the open radical prostatectomy, whereas there was no significant difference in the positive surgical margin rates between robot-assisted radical prostatectomy and laparoscopic radical prostatectomy. In the multivariable analysis, PSA level at diagnosis and surgical approach (open radical prostatectomy vs robot-assisted radical prostatectomy) were independent risk factors for positive surgical margin. The apex was the most common location of positive surgical margin in the open radical prostatectomy and laparoscopic radical prostatectomy groups, whereas the bladder neck was the most common location in the robot-assisted radical prostatectomy group. The significant difference of positive surgical margin locations continued after the propensity score adjustment. Robot-assisted radical prostatectomy may potentially achieve the lowest positive surgical margin rate among three surgical approaches. The bladder neck was the most common location of positive surgical margin in robot-assisted radical prostatectomy and apex in open radical prostatectomy and laparoscopic radical prostatectomy. Although robot-assisted radical prostatectomy may contribute to the reduction of positive surgical margin, dissection of the bladder neck requires careful attention to avoid positive surgical margins.

A novel technique for robot assisted latissimus dorsi flap harvest.

PubMed

Chung, Jae-Hyun; You, Hi-Jin; Kim, Hyon-Surk; Lee, Byung-Il; Park, Seung-Ha; Yoon, Eul-Sik

2015-07-01

A robotic surgery technique of harvesting the latissimus dorsi muscle flap has technical advantages over endoscopic harvest and cosmetic advantages over the open technique. The authors introduce a new transaxillary gasless technique using an articulated long retractor for robot assisted latissimus dorsi flap harvest. Twelve robot assisted latissimus dorsi muscle flaps were harvested: 3 cases of delayed reconstruction following tissue expander insertion or breast conserving surgery; 4 cases of immediate reconstruction following nipple-sparing mastectomy; and 5 cases of chest wall deformity correction in patients with Poland syndrome. A specially designed articulated long retractor was used to maintain adequate working space and enable latissimus dorsi muscle dissection without gas insufflation. Twelve muscle flaps were successfully harvested in 12 patients without converting to an open technique. The mean docking time was 54.6 min, and the mean operative time and robotic time were 400.4 min and 85.8 min, respectively. There were no donor site complications or flap problems. Average follow-up was 15.7 months. All patients were satisfied with their esthetic results, especially the absence of visible scars. The novel robot assisted latissimus dorsi harvest technique is a safe alternative to the conventional method. Copyright © 2015. Published by Elsevier Ltd.

Technical considerations to minimize complications of inguinal lymph node dissection

PubMed Central

Gupta, Manik K.; Patel, Amar P.

2017-01-01

Penile cancer is a rare malignancy with a high propensity for regional dissemination. Current guidelines recommend inguinal lymphadenectomy in patients with penile cancer for palpable inguinal lymph nodes or in certain cases of nonpalpable inguinal lymph nodes. For many years, this procedure was performed with a traditional open approach and carried significant morbidity due to severe lymphedema, flap necrosis, wound infections, and seroma formation. The evolution of inguinal lymphadenectomy surgery for patients with penile cancer to a more minimally invasive approach has greatly reduced the morbidity of the procedure. Complications of inguinal lymphadenectomy can be minimized with modifications in surgical approach with the use of endoscopic, robotic, and various reconstructive methods. This review focuses on various intraoperative techniques to reduce morbidity in inguinal lymphadenectomies for penile cancer. PMID:29184778

Robotic inferior vena cava surgery.

PubMed

Davila, Victor J; Velazco, Cristine S; Stone, William M; Fowl, Richard J; Abdul-Muhsin, Haidar M; Castle, Erik P; Money, Samuel R

2017-03-01

Inferior vena cava (IVC) surgery is uncommon and has traditionally been performed through open surgical approaches. Renal cell carcinoma with IVC extension generally requires vena cavotomy and reconstruction. Open removal of malpositioned IVC filters (IVCF) is occasionally required after endovascular retrieval attempts have failed. As our experience with robotic surgery has advanced, we have applied this technology to surgery of the IVC. We reviewed our institution's experience with robotic surgical procedures involving the IVC to determine its safety and efficacy. All patients undergoing robotic surgery that included cavotomy and repair from 2011 to 2014 were retrospectively reviewed. Data were obtained detailing preoperative demographics, operative details, and postoperative morbidity and mortality. Ten patients (6 men) underwent robotic vena caval procedures at our institution. Seven patients underwent robotic nephrectomy with removal of IVC tumor thrombus and retroperitoneal lymph node dissection. Three patients underwent robotic explantation of an IVCF after multiple endovascular attempts at removal had failed. The patients with renal cell carcinoma were a mean age of was 65.4 years (range, 55-74 years). Six patients had right-sided malignancy. All patients had T3b lesions at time of diagnosis. Mean tumor length extension into the IVC was 5 cm (range, 1-8 cm). All patients underwent robotic radical nephrectomy, with caval tumor thrombus removal and retroperitoneal lymph node dissection. The average operative time for patients undergoing surgery for renal cell carcinoma was 273 minutes (range, 137-382 minutes). Average intraoperative blood loss was 428 mL (range, 150-1200 mL). The patients with IVCF removal were a mean age of 33 years (range, 24-41 years). Average time from IVCF placement until robotic removal was 35.5 months (range, 4.3-57.3 months). Before robotic IVCF removal, a minimum of two endovascular retrievals were attempted. Average operative time for patients undergoing IVCF removal was 163 minutes (range, 131-202 minutes). Intraoperative blood loss averaged 250 mL (range, 150-350 mL). All procedures were completed robotically. The mean length of stay for all patients was 3.5 days (range, 1-8 days). All patients resumed ambulation on postoperative day 1. Nine patients resumed a regular diet on postoperative day 2. One patient with a renal tumor sustained a colon injury during initial adhesiolysis, before robotic radical nephrectomy, which was recognized at the initial operation and repaired robotically. Robotic radical nephrectomy and caval tumor removal were then completed. No blood transfusions were required intraoperatively, but three patients required blood transfusions postoperatively. Although robotic IVC surgery is uncommon, our initial limited experience demonstrates it is safe and efficacious. Copyright © 2016 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.

Indocyanine Green Guided Pelvic Lymph Node Dissection: An Efficient Technique to Classify the Lymph Node Status of Patients with Prostate Cancer Who Underwent Radical Prostatectomy.

PubMed

Ramírez-Backhaus, Miguel; Mira Moreno, Alejandra; Gómez Ferrer, Alvaro; Calatrava Fons, Ana; Casanova, Juan; Solsona Narbón, Eduardo; Ortiz Rodríguez, Isabel María; Rubio Briones, José

2016-11-01

We evaluated the effectiveness of indocyanine green guided pelvic lymph node dissection for the optimal staging of prostate cancer and analyzed whether the technique could replace extended pelvic lymph node dissection. A solution of 25 mg indocyanine green in 5 ml sterile water was transperineally injected. Pelvic lymph node dissection was started with the indocyanine green stained nodes followed by extended pelvic lymph node dissection. Primary outcome measures were sensitivity, specificity, predictive value and likelihood ratio of a negative test of indocyanine green guided pelvic lymph node dissection. A total of 84 patients with a median age of 63.55 years and a median prostate specific antigen of 8.48 ng/ml were included in the study. Of these patients 60.7% had intermediate risk disease and 25% had high or very high risk disease. A median of 7 indocyanine green stained nodes per patient was detected (range 2 to 18) with a median of 22 nodes excised during extended pelvic lymph node dissection. Lymph node metastasis was identified in 25 patients, 23 of whom had disease properly classified by indocyanine green guided pelvic lymph node dissection. The most frequent location of indocyanine green stained nodes was the proximal internal iliac artery followed by the fossa of Marcille. The negative predictive value was 96.7% and the likelihood ratio of a negative test was 8%. Overall 1,856 nodes were removed and 603 were stained indocyanine green. Pathological examination revealed 82 metastatic nodes, of which 60% were indocyanine green stained. The negative predictive value was 97.4% but the likelihood ratio of a negative test was 58.5%. Indocyanine green guided pelvic lymph node dissection correctly staged 97% of cases. However, according to our data it cannot replace extended pelvic lymph node dissection. Nevertheless, its high negative predictive value could allow us to avoid extended pelvic lymph node dissection if we had an accurate intraoperative lymph fluorescent analysis. Copyright © 2016 American Urological Association Education and Research, Inc. Published by Elsevier Inc. All rights reserved.

Long-term prognoses and outcomes of axillary lymph node recurrence in 2,578 sentinel lymph node-negative patients for whom axillary lymph node dissection was omitted: results from one Japanese hospital.

PubMed

Ogiya, Akiko; Kimura, Kiyomi; Nakashima, Eri; Sakai, Takehiko; Miyagi, Yumi; Iijima, Kotaro; Morizono, Hidetomo; Makita, Masujiro; Horii, Rie; Akiyama, Futoshi; Iwase, Takuji

2016-03-01

Axillary dissection omission for sentinel lymph node-negative patients has been a practice at Cancer Institute Hospital, Japanese Foundation for Cancer Research since 2003. We examined the long-term results of omission of axillary dissection in sentinel lymph node-negative patients treated at our hospital, as well as their axillary lymph node recurrence characteristics and outcomes. Our study included 2,578 patients with cTis or T1-T3N0M0 primary breast cancer for whom dissection was omitted because they were sentinel lymph node negative. The median observation period was 75 months. In sentinel lymph node-negative patients for whom dissection was omitted, the rates of axillary lymph node recurrence, distant recurrence, and breast cancer mortality were 0.9, 2, and 1 %, respectively. Eighteen patients underwent additional dissection if axillary lymph node recurrence was observed at the first recurrence. Four triple-negative (TN) patients experienced distant recurrence after additional dissection. All four patients were administered anticancer agents after axillary lymph node recurrence and experienced recurrence within 1 year of additional dissection. The axillary lymph node recurrence rate was 0.8 % for luminal and 4.5 % for TN subtypes. The long-term prognoses of patients for whom dissection was omitted owing to negative sentinel lymph node metastases were similar to those reported previously-low recurrence and mortality rates. The frequency of axillary lymph node recurrence and the post-recurrence outcome differed between luminal and TN cases, with recurrence being more frequent in patients with the TN subtype. TN patients also had poorer prognoses, even after receiving additional dissection and anticancer agents after recurrence.

Robot-assisted laparoscopic transperitoneal infrarenal lymphadenectomy in patients with locally advanced cervical cancer by single docking: Do we need a backup procedure?

PubMed

Gucer, Fatih; Misirlioglu, Selim; Ceydeli, Nuri; Taskiran, Cagatay

2018-03-01

To present our initial experience on the feasibility of robotic transperitoneal para-aortic lymphadenectomy up to left renal vein via single docking approach by high port insertion technique followed by left shoulder docking as a rescue backup procedure in surgically obstructed patients undergoing surgical staging because of locally advanced cervical cancer (LACC). Prospective observational preliminary study. Canadian Task Force classification II-3. Tertiary-care academic affiliated private hospital. Ten patients with LACC who underwent robotic transperitoneal infrarenal para-aortic lymphadenectomy between January 2012 and December 2014. All patients with pathologically proven cervical cancer underwent a PET/CT scanning in a similar fashion at the department of nuclear medicine. PET/CT scans were evaluated by the nuclear medicine specialist. Following pre-operative work-up, robot-assisted transperitoneal infrarenal para-aortic lymphadenectomy was performed up to left renal vein by the same experienced surgeon. Sections of 5 mm were performed and stained with routine hematoxylin and eosin (H&E), and node count was done separately by experienced gynecopathologist. During the study period, 12 consecutive patients with LACC were counseled for pre-therapeutic robot-assisted transperitoneal para-aortic lymphadenectomy. Two patients declined the procedure and underwent standardized chemo-radiation therapy whereas remaining ten patients constituted the study group. In the study group, the median age was 46 years (range 33-59 years), and the median body mass index 28.5 kg/m 2 (range 18.5-35.1 kg/m 2 ). Clinical staging was stage IIB in four patients, IIIB in four, and IVA in one. Histopathological diagnosis was squamous cell carcinoma in nine patients, and adenocarcinoma in one. On PET/CT scans, seven out of ten patients were positive for pelvic lymph node metastasis. With respect to para-aortic area, only one of the ten patients had suspected metastasis in PET/CT. For nine patients with LACC, the median docking time was 6.5 min (range 4-15 min), and the median operating time for para-aortic lymphadenectomy was 120 min (range 60-165 min). The median trocar time was 14.5 min (range 5-45 min). In two out of ten patients, the surgical removal of whole lymphatic tissue between inferior mesenteric artery and left renal vein was not completely possible by a single docking of robotic column. Therefore, a new optic trocar was placed in the umbilicus and the robotic column was relocated over the left shoulder of the patient and residual lymphatic tissue measuring approximately 2 cm in the long axis immediately below the left renal vein was removed and the surgery was completed up to the left renal vein. All para-aortic lymphadenectomies have been completed by robotic route. There were no intra-operative complications. No patient received a blood transfusion. Early post-operative grade 2 and 3a complications according to Dindo classification occurred in two patients: one symptomatic lymphocyst and one local infection on assistant port site in one patient. The patient with suspected para-aortic lymph node metastasis in PET/CT showed no metastatic disease on histopathologic exam of para-aortic lymph nodes. The patient with recurrent disease and negative para-aortic lymph nodes on frozen section examination underwent robot-assisted total pelvic exenteration. Five of the residual eight patients had histologically proven metastasis in the para-aortic lymph node(s). Treatment modification occurred in six patients related to pre-treatment staging surgery. According to pathological results, extended field radiation therapy has been added in five patients and it was omitted in one patient. The median time interval between surgery and initiation of radiotherapy was 12 days (range 6-23 days). Robotic transperitoneal infrarenal para-aortic lymphadenectomy up to left renal vein by high port insertion technique is a safe and feasible option for staging and treatment planning. However, technically, it is obstructed in a small group of patients and nodal staging surgery up to left renal vein can be completed by consecutive left shoulder docking approach as a backup rescue plan.

Robot-assisted laparoscopic staging surgery for endometrial cancer--a preliminary report.

PubMed

Lee, Chyi-Long; Han, Chien-Min; Su, Hsuan; Wu, Kai-Yun; Wang, Chin-Jung; Yen, Chih-Feng

2010-12-01

The robotic surgical system is reported to overcome some technical difficulties in traditional laparoscopic hysterectomy. This study aimed to evaluate the feasibility and surgical outcomes of a robotic surgery program for endometrial cancer. Patients with endometrial cancer with the intention to receive treatment using robot-assisted laparoscopic staging surgery were recruited in a university hospital from July 2007 to August 2008. All of these surgeries were performed with the da Vinci system. Six patients (mean age, 47.5 ±1.4 years; mean body mass index, 26.2 ±3.5 kg/m(2)) were enrolled and completed robot-assisted laparoscopic staging surgery. The robot docking time was 45.0 ±13.6 minutes and the robot-assisted operation time was 200.3 ±30.0 minutes. The mean estimated blood loss was 180.0 ±147.6 mL. The mean number of lymph nodes retrieved was 23.2 ±7.4. No laparoconversion and no intraoperative or postoperative complications occurred. All patients were alive and free of disease up to the date of this report, at a median follow-up of 6.5 months (range, 5-17 months). Robot-assisted laparoscopic staging surgery is a feasible treatment and helps overcome the technical limitations in conventional laparoscopy for endometrial cancer. Copyright © 2010 Taiwan Association of Obstetric & Gynecology. Published by Elsevier B.V. All rights reserved.

[Initial results of robotic esophagectomy for esophageal cancer].

PubMed

Trugeda Carrera, M Soledad; Fernández-Díaz, M José; Rodríguez-Sanjuán, Juan Carlos; Manuel-Palazuelos, José Carlos; de Diego García, Ernesto Matias; Gómez-Fleitas, Manuel

2015-01-01

There is scant experience with robot-assisted esophagectomy in cases of esophageal and gastro-esophageal junction cancer. Our aim is to report our current experience. Observational cohort study of the first 32 patients who underwent minimally invasive esophagectomy for esophageal cancer from September 2011 to June 2014. The gastric tube was created laparoscopically. In the thoracic field, a robot-assisted thoracoscopic approach was performed in the prone position with intrathoracic robotic hand-sewn anastomosis. Patient and tumour characteristics, surgical technique, short-term outcomes (morbidity and mortality) and oncological results (radicality and number of removed nodes) were evaluated. Thirty-two patients, with a mean age of 58 years (34-74) were treated by a totally minimally invasive esophagectomy: robotic laparoscopy and thoracoscopy (11 McKeown and 21 Ivor-Lewis). Twenty-nine received neoadjuvant chemoradiotherapy. There were no conversions to open surgery. Console time was 218minutes (190-285). Blood loss was 170ml (40-255). One patient died from cardiac disease. Nine patients had a major complication (Dindo-Clavien grade II or higher). There was no case of respiratory complication or recurrent laryngeal nerve palsy. Five patients had intrathoracic fistula, 4 radiological and one clinical. Three had chylothorax, 2 cervical fistula and one gastric tube necrosis. The median hospital stay was 12 days (8-50). All the resections were R0 and the median of removed lymph nodes was 16 (2-23). Our results suggest that minimally invasive esophagectomy with robot-assisted thoracoscopy is safe and achieves oncological standards. Copyright © 2014 AEC. Publicado por Elsevier España, S.L.U. All rights reserved.

Early experience using the da Vinci Surgical System for the treatment of mediastinal tumors.

PubMed

Kajiwara, Naohiro; Taira, Masahiro; Yoshida, Koichi; Hagiwara, Masaru; Kakihana, Masatoshi; Usuda, Jitsuo; Uchida, Osamu; Ohira, Tatsuo; Kawate, Norihiko; Ikeda, Norihiko

2011-10-01

The da Vinci Surgical System has been used in only a few cases for treating mediastinal tumors in Japan. Recently, we used the da Vinci Surgical System for various types of anterior and middle mediastinal tumors in clinical practice. We report our early experience using the da Vinci Surgical System. Seven patients gave written informed consent to undergo robotic surgery for mediastinal tumor dissection using the da Vinci Surgical System. We evaluated the safety and feasibility of this system for the surgical treatment of mediastinal tumors. Two specialists in thoracic surgery who are certified to use the da Vinci S Surgical System and another specialist acted as an assistant performed the tumor dissection. We were able to access difficult-to-reach areas, such as the mediastinum, safely. All the resected tumors were classified as benign tumors histologically. The average da Vinci setting time was 14.0 min, the average working time was 55.7 min, and the average overall operating time was 125.9 min. The learning curve for the da Vinci setup and manipulation time was short. Robotic surgery enables mediastinal tumor dissection in certain cases more safely and easily than conventional video-assisted thoracoscopic surgery and less invasively than open thoracotomy.

Robot-assisted pudendal neurolysis in the treatment of pudendal nerve entrapment syndrome.

PubMed

Moscatiello, P; Carracedo Calvo, D; Yupanqui Guerra, L; Rivera Martínez, M E; Mendiola de la Hoza, A; Sánchez Encinas, M

2018-06-01

Pudendal nerve entrapment syndrome (PNE) is characterised by the presence of neuropathic pain in the pudendal nerve (PN) territory, associated or not with urinary, defecatory and sexual disorders. Surgical PN decompression is an effective and safe alternative for cases when conservative treatment fails. The aim of this study is to describe the first robot-assisted pudendal neurolysis procedure performed in our country. We describe step by step the technique of robot-assisted laparoscopic neurolysis of the left PN performed with intraoperative neurophysiological monitoring on a 60-year-old patient diagnosed with left PNE. The procedure was performed satisfactorily without complications. After 24h, the patient was discharged from the hospital. We observed a 50% reduction in pain measured using the visual analogue scale 2 weeks after the procedure, which remained after 10 weeks of the neurolysis. Robot-assisted neurolysis of the PN constitutes a feasible and safe approach, enabling better visualisation and accuracy in the dissection of the PN. Intraoperative neurophysiological monitoring is useful for locating the PN and for detecting intraoperative changes after the release of the nerve. Copyright © 2018 AEU. Publicado por Elsevier España, S.L.U. All rights reserved.

Risk factors for postoperative complications in robotic general surgery.

PubMed

Fantola, Giovanni; Brunaud, Laurent; Nguyen-Thi, Phi-Linh; Germain, Adeline; Ayav, Ahmet; Bresler, Laurent

2017-03-01

The feasibility and safety of robotically assisted procedures in general surgery have been reported from various groups worldwide. Because postoperative complications may lead to longer hospital stays and higher costs overall, analysis of risk factors for postoperative surgical complications in this subset of patients is clinically relevant. The goal of this study was to identify risk factors for postoperative morbidity after robotic surgical procedures in general surgery. We performed an observational monocentric retrospective study. All consecutive robotic surgical procedures from November 2001 to December 2013 were included. One thousand consecutive general surgery patients met the inclusion criteria. The mean overall postoperative morbidity and major postoperative morbidity (Clavien >III) rates were 20.4 and 6 %, respectively. This included a conversion rate of 4.4 %, reoperation rate of 4.5 %, and mortality rate of 0.2 %. Multivariate analysis showed that ASA score >3 [OR 1.7; 95 % CI (1.2-2.4)], hematocrit value <38 [OR 1.6; 95 % CI (1.1-2.2)], previous abdominal surgery [OR 1.5; 95 % CI (1-2)], advanced dissection [OR 5.8; 95 % CI (3.1-10.6)], and multiquadrant surgery [OR 2.5; 95 % CI (1.7-3.8)] remained independent risk factors for overall postoperative morbidity. It also showed that advanced dissection [OR 4.4; 95 % CI (1.9-9.6)] and multiquadrant surgery [OR 4.4; 95 % CI (2.3-8.5)] remained independent risk factors for major postoperative morbidity (Clavien >III). This study identifies independent risk factors for postoperative overall and major morbidity in robotic general surgery. Because these factors independently impacted postoperative complications, we believe they could be taken into account in future studies comparing conventional versus robot-assisted laparoscopic procedures in general surgery.

Robotic Approach in Benign and Malignant Esophageal Tumors; A Preliminary Seven Case Series.

PubMed

Tomulescu, Victor; Stanescu, Codrut; Blajut, Cristian; Barbulescu, Loredana; Droc, Gabriela; Herlea, Vlad; Popescu, Irinel

2018-01-01

Esophageal surgery has been recognized as very challenging for surgeons and risky for patients. Thoracoscopic approach have proved its benefit in esophageal surgery but has some drawbacks as tremor and limited degrees of freedom, contra-intuitive movements and fulcrum effect of the surgical tools. Robotic technology has been developed with the intent to overcome these limitations of the standard laparoscopy or thoracoscopy. These benefits of robotic procedure are most advantageous when operating in remote areas difficult to reach as in esophageal surgery. The aim of this paper is to present our small experience related with robotic approach in benign and malignant esophageal tumors and critically revise the evidence available about the use of the robotic technology for the treatment of these pathology. Methods: From January 2008 to September 2016 robotic surgery interventions related with benign or malignant esophageal tumors were performed in "Dan Setlacec" Center for General Surgery and Liver Transplantation of Fundeni Clinical Institute in seven patients. This consisted of dissection of the entire esophagus as part of an abdomino-thoracic-cervical procedure for esophageal cancer in 3 patients and the extirpation of an esophageal leiomyoma in 3 cases and a foregut esophageal cyst in one case. Results: All procedures except one were completed entirely using the da Vinci robotic system. The exception was the first case - a 3 cm leiomyoma of the inferior esophagus with ulceration of the superjacent esophageal mucosa. Pathology reports revealed three esophageal leiomyoma, one foregut cyst and three squamous cell carcinomas with free of tumor resection margins. The mean number of retrieved mediastinal nodes was 24 (22 - 27). The postoperative course was uneventful in four cases, in the other three a esophageal fistula occurred in the converted leiomyoma case (closed in the 14th postoperative day), a prolonged drainage in one esophageal cancer case and a temporary right recurrent nerve palsy in an other one. One patient with esophageal cancer and all patients with benign lesions are alive with no signs of recurrence and no symptomatology. Our experience is limited and we cannot conclude for the long term benefits of robotic surgery for esophageal tumors. In our experience the early outcomes were better then using classic open approach, but similar with the cases performed by thoracoscopic approach. We have noticed significant advantages of robotic surgery in relation of lymph node retrieval, leiomyoma dissection safe from esophageal mucosa and suturing. Ergonomics for the surgeon was incomparable better then with the thoracoscopic approach. Celsius.

Sentinel lymph node mapping in endometrial cancer: a systematic review and meta-analysis.

PubMed

Lin, Hefeng; Ding, Zheyuan; Kota, Vishnu Goutham; Zhang, Xiaoming; Zhou, Jianwei

2017-07-11

Endometrial cancer is the most frequent tumor in the female reproductive system, while the sentinel lymph node (SLN) mapping for diagnostic efficacy of endometrial cancer is still controversial. This meta-analysis was conducted to evaluate the diagnostic value of SLN in the assessment of lymph nodal involvement in endometrial cancer. Forty-four studies including 2,236 cases were identified. The pooled overall detection rate was 83% (95% CI: 80-86%). The pooled sensitivity was 91% (95% CI: 87-95%). The bilateral pelvic node detection rate was 56% (95% CI: 48-64%). Use of indocyanine green (ICG) increased the overall detection rate to 93% (95% CI: 89-96%) and robotic-assisted surgery also increased the overall detection rate to 86% (95% CI: 79-93%). In summary, our meta-analysis provides strong evidence that sentinel node mapping is an accurate and feasible method that performs well diagnostically for the assessment of lymph nodal involvement in endometrial cancer. Cervical injection, robot-assisted surgery, as well as using ICG, optimized the sensitivity and detection rate of the technique. Sentinel lymph mapping may potentially leading to a greater utilization by gynecologic surgeons in the future.

Partial lower axillary dissection for patients with clinically node-negative breast cancer.

PubMed

Kodama, H; Mise, K; Kan, N

2012-01-01

To evaluate retrospectively the outcomes of partial lower axillary lymph node dissection caudal to the intercostobrachial nerve in patients with clinically node-negative (N(0)) breast cancer. Numbers of dissected and metastatic nodes, overall and disease-free survival rates, postoperative complication rates, and axillary recurrence were compared between patients who underwent breast cancer surgery with partial axillary node dissection (n = 1043) and historical controls who underwent conventional dissection (n = 1084). The 5-year overall and disease-free survival rates were 95.6% and 89.7%, and 94.9% and 88.4%, respectively, in the partial dissection and conventional dissection groups; the differences were not significant. Mean duration of surgery (41.6 min versus 60.9 min), intraoperative blood loss (28.0 ml versus 51.3 ml), volume of lymphatic drainage at 2 weeks postoperatively (488 ml versus 836 ml), and persistent arm lymphoedema (0.0% versus 11.8%) were significantly different between the partial and conventional dissection groups, respectively. Partial axillary lymph node dissection was associated with similar survival rates (but lower postoperative complication rates) compared with conventional axillary dissection and is recommended in patients with N(0) breast cancer.

General surgery training and robotics: Are residents improving their skills?

PubMed

Finnerty, Brendan M; Afaneh, Cheguevara; Aronova, Anna; Fahey, Thomas J; Zarnegar, Rasa

2016-02-01

While robotic-assisted operations have become more prevalent, many general surgery residencies do not have a formal robotic training curriculum. We sought to ascertain how well current general surgery training permits acquisition of robotic skills by comparing robotic simulation performance across various training levels. Thirty-six participants were categorized by level of surgical training: eight medical students (MS), ten junior residents (JR), ten mid-level residents (MLR), and eight senior residents (SR). Participants performed three simulation tasks on the da Vinci (®) Skills Simulator (MatchBoard, EnergyDissection, SutureSponge). Each task's scores (0-100) and cumulative scores (0-300) were compared between groups. There were no differences in sex, hand dominance, video gaming history, or prior robotic experience between groups; however, SR was the oldest (p < 0.001). The median overall scores did not differ: 188 (84-201) for MS, 183 (91-234) for JR, 197 (153-218) for MLR, and 205 (169-229) for SR (p = 0.14). The median SutureSponge score was highest for SR (61, range 39-81) compared to MS (43, range 26-61), JR (43, range 11-72), and MLR (55, range 36-68) (p = 0.039). However, there were no significant differences in MatchBoard (p = 0.27) or EnergyDissection (p = 0.99) scores between groups. There was a positive correlation between SutureSponge score and number of laparoscopic cases logged (p = 0.005, r(2) = 0.21), but this correlation did not exist for the MatchBoard or EnergyDissection tasks. Lastly, there was no correlation between total lifetime hours of video gaming and overall score (p = 0.89, R(2) = 0.0006). Robotic skillsets acquired during general surgery residency show minimal improvement during the course of training, although laparoscopic experience is correlated with advanced robotic task performance. Changes in residency curricula or pursuit of fellowship training may be warranted for surgeons seeking proficiency.

[Historical outline on the nomenclature of neck lymph nodes as a basis of neck dissection classification].

PubMed

Werner, J A

2001-07-01

The neck dissection classification is based considerably on the organization of the lymph nodes of the neck. Terminology and anatomical allocation of nearly 300 cervicofacial lymph nodes repeatedly changed since the beginning of the 20th century. Analysis of the literature on neck lymph node organization with reference to the development of the neck dissection classification. The first fundamental nomenclature of the neck lymph nodes is founded on the work of Rouviére (1932). Suárez (1963) described the functional neck dissection on the basis of the fascial compartmentalization of the neck. Lindberg (1972) left the predominantly anatomically correlated grouping of the cervical lymph nodes as described by Rouviére and divided the lymphatic system of the neck on basis of pathophysiological mechanisms. The attention regarding the location of occult metastases led to the description of the selective neck dissection. Since the fundamental work of Shah et al. (1981) there was a multiplicity of more or less slight changes of the neck node regions. These changes were again basis for new neck dissection terminologies. A new classification was introduced in the year 2000 as the revised version of the American Head and Neck Society. The revised version of the neck dissection classification can reduce former controversies, particularly regarding an optimized intraoperative allocation of the lymph nodes and a simplified terminology of the selective neck dissection. With the goal of a standardization of the neck dissection forms it remains to be seen if the proponents of the functional neck dissection after Suárez consider the extent of the neck dissection in patients with N0 neck in favor of the selective neck dissection.

The economics of robotic cystectomy: cost comparison of open versus robotic cystectomy.

PubMed

Lee, Richard; Ng, Casey K; Shariat, Shahrokh F; Borkina, Anna; Guimento, Robert; Brumit, Kevin F; Scherr, Douglas S

2011-12-01

• To assess and compare the economic burden of open radical cystectomy (OC) vs robotic-assisted laparoscopic radical cystectomy (RC) with pelvic lymph node dissection and urinary diversion. • A series of 103 and 83 consecutive patients undergoing OC and RC, respectively, were prospectively studied at a tertiary care institution from April 2002 to February 2009. • Data were collected on patient demographics, perioperative parameters and length of stay (LOS) in hospital. Cohorts were subdivided into ileal conduit (IC), continent cutaneous diversion (CCD) and orthotopic neobladder (ON) subgroups. • A linear cost model was created to simulate treatment with OC vs RC. Procedural costs were derived from the Medicare Resource Based Relative Value Scale. Materials costs were obtained from the respective suppliers. The indirect costs of complications were considered. • Sensitivity analyses were performed. • Despite a higher cost of materials, RC was less expensive than OC for IC and CCD, although the cost advantage deteriorated for ON. • The per-case costs of RC with IC, CCD and ON were $20,659, $22,102 and $22,685, respectively, compared to $25,505, $22,697 and $20,719 for their OC counterparts. • The largest cost driver in the study was LOS in hospital. • RC showed a shorter LOS compared to OC, although this effect was insufficient to offset the higher cost of robotic surgery. • Complications materially affected cost performance. • Despite a higher cost of materials, RC can be more cost efficient than OC as a treatment for bladder cancer at a high-volume, tertiary care referral centre, particularly with IC. • Complications significantly impact cost performance. © 2011 THE AUTHORS. BJU INTERNATIONAL © 2011 BJU INTERNATIONAL.

Full High-definition three-dimensional gynaecological laparoscopy--clinical assessment of a new robot-assisted device.

PubMed

Tuschy, Benjamin; Berlit, Sebastian; Brade, Joachim; Sütterlin, Marc; Hornemann, Amadeus

2014-01-01

To investigate the clinical assessment of a full high-definition (HD) three-dimensional robot-assisted laparoscopic device in gynaecological surgery. This study included 70 women who underwent gynaecological laparoscopic procedures. Demographic parameters, type and duration of surgery and perioperative complications were analyzed. Fifteen surgeons were postoperatively interviewed regarding their assessment of this new system with a standardized questionnaire. The clinical assessment revealed that three-dimensional full-HD visualisation is comfortable and improves spatial orientation and hand-to-eye coordination. The majority of the surgeons stated they would prefer a three-dimensional system to a conventional two-dimensional device and stated that the robotic camera arm led to more relaxed working conditions. Three-dimensional laparoscopy is feasible, comfortable and well-accepted in daily routine. The three-dimensional visualisation improves surgeons' hand-to-eye coordination, intracorporeal suturing and fine dissection. The combination of full-HD three-dimensional visualisation with the robotic camera arm results in very high image quality and stability.

Robotic radical perineal cystectomy and extended pelvic lymphadenectomy: initial investigation using a purpose-built single-port robotic system.

PubMed

Maurice, Matthew J; Kaouk, Jihad H

2017-12-01

To assess the feasibility of radical perineal cystoprostatectomy using the latest generation purpose-built single-port robotic surgical system. In two male cadavers the da Vinci ® SP1098 Surgical System (Intuitive Surgical, Sunnyvale, CA, USA) was used to perform radical perineal cystoprostatectomy and bilateral extended pelvic lymph node dissection (ePLND). New features in this model include enhanced high-definition three-dimensional optics, improved instrument manoeuvrability, and a real-time instrument tracking and guidance system. The surgery was accomplished through a 3-cm perineal incision via a novel robotic single-port system, which accommodates three double-jointed articulating robotic instruments, an articulating camera, and an accessory laparoscopic instrument. The primary outcomes were technical feasibility, intraoperative complications, and total robotic operative time. The cases were completed successfully without conversion. There were no accidental punctures or lacerations. The robotic operative times were 197 and 202 min. In this preclinical model, robotic radical perineal cystoprostatectomy and ePLND was feasible using the SP1098 robotic platform. Further investigation is needed to assess the feasibility of urinary diversion using this novel approach and new technology. © 2017 The Authors BJU International © 2017 BJU International Published by John Wiley & Sons Ltd.

Alternative paratracheal lymph node dissection in left-sided hilar lung cancer patients: comparing the number of lymph nodes dissected to the number of lymph nodes dissected in right-sided mediastinal dissections.

PubMed

Toker, Alper; Tanju, Serhan; Ziyade, Sedat; Kaya, Serkan; Erus, Suat; Ozkan, Berker; Yilmazbayhan, Dilek

2011-06-01

Removing or sampling lymph nodes from the bilateral paratracheal area through a left thoracotomy is not a standard procedure in patients with lung cancer. The aim of this study was to evaluate the feasibility of a technique without ductus arteriosus division and mobilization of the aortic arch and to compare the number of lymph nodes resected in left-sided dissections to the number of lymph nodes removed in right-sided mediastinal dissections that are routinely performed in clinical practice. A total of 93 patients with hilar lung cancer were evaluated. A prospective study was conducted on 51 patients with primary left-sided hilar lung cancer, who underwent left thoracotomy and paratracheal lymphadenectomy between January 2008 and January 2010. The number of nodes dissected in these patients was compared with the number of nodes dissected in 42 patients with right-sided hilar lung cancer by right-sided mediastinal dissection within the same period. The mean number of resected nodes in the bilateral paratracheal area via left thoracotomy was 8.4 (2-18 nodes). The distribution from 4R-4L-2L-2R was as follows: 3.3-2.5-0.5-2.1, respectively. Six patients (11.7%) were diagnosed with occult N2, and two (3.9%) of these patients also had N3 disease concomitantly. The number of dissected nodes from the ipsilateral station 2 via right-sided versus left-sided thoracotomy was 1.6 versus 0.5 (p=0.000), whereas the number of dissected nodes from ipsilateral station 4 via right-sided versus left-sided thoracotomy was 3.3 versus 2.5, respectively (p=0.1). The number of dissected nodes from the contralateral station 2 via right-sided versus left-sided thoracotomy was 0.2 versus 2.1 (p=0.000), whereas those numbers from the contralateral station 4 via right-sided versus left-sided thoracotomy were 1.0 versus 3.3, respectively (p=0.000). Lymphadenectomy of the paratracheal area via left thoracotomy without ductus arteriosus division and mobilization of the aortic arch is technically feasible. From these data, regardless of approach, more lymph nodes are obtained from the right paratracheal space; this appears to be due to the fact that there are more right-sided paratracheal lymph nodes. Copyright © 2010 European Association for Cardio-Thoracic Surgery. Published by Elsevier B.V. All rights reserved.

Stratified analysis of 800 Asian patients after robot-assisted radical prostatectomy with a median 64 months of follow up.

PubMed

Abdel Raheem, Ali; Kim, Dae Keun; Santok, Glen Denmer; Alabdulaali, Ibrahim; Chung, Byung Ha; Choi, Young Deuk; Rha, Koon Ho

2016-09-01

To report the 5-year oncological outcomes of robot-assisted radical prostatectomy from the largest series ever reported from Asia. A retrospective analysis of 800 Asian patients who were treated with robot-assisted radical prostatectomy from July 2005 to May 2010 in the Department of Urology and Urological Science Institute, Yonsei University College of Medicine, Seoul, Korea was carried out. The primary end-point was to evaluate the biochemical recurrence. The secondary end-point was to show the biochemical recurrence-free survival, metastasis-free survival and cancer-specific survival. A total of 197 (24.65%), 218 (27.3%), and 385 (48.1%) patients were classified as low-, intermediate- and high-risk patients according to the D'Amico risk stratification risk criteria, respectively. The median follow-up period was 64 months (interquartile range 28-71 months). The overall incidence of positive surgical margin was 36.6%. There was biochemical recurrence in 183 patients (22.9%), 38 patients (4.8%) developed distant metastasis and 24 patients (3%) died from prostate cancer. Actuarial biochemical recurrence-free survival, metastasis-free survival, and cancer-specific survival rates at 5 years were 76.4%, 94.6% and 96.7%, respectively. Positive lymph node was associated with lower 5-year biochemical recurrence-free survival (9.1%), cancer-specific survival (75.7%) and metastasis-free survival (61.9%) rates (P < 0.001). On multivariable analysis, among all the predictors, positive lymph node was the strongest predictor of biochemical recurrence, cancer-specific survival and metastasis-free survival (P < 0.001). Herein we report the largest robot-assisted radical prostatectomy series from Asia. Robot-assisted radical prostatectomy is confirmed to be an oncologically safe procedure that is able to provide effective 5-year cancer control, even in patients with high-risk disease. © 2016 The Japanese Urological Association.

Extent of surgery for papillary thyroid cancer: preoperative imaging and role of prophylactic and therapeutic neck dissection.

PubMed

Cisco, Robin M; Shen, Wen T; Gosnell, Jessica E

2012-03-01

Papillary thyroid cancer (PTC) has an excellent prognosis, yet lymph node metastases are common. Most authors agree that central and/or lateral lymph node dissection should be undertaken in patients with abnormal lymph nodes detected on ultrasound, physical examination or intraoperative inspection. However the appropriate extent of prophylactic lymph node dissection for clinically node-negative patients remains the subject of controversy. There have been no randomized trials to date to offer guidance on this issue. The 2006 guidelines of the American Thyroid Association recommended consideration of prophylactic bilateral central lymph node dissection (CLND) for all patients undergoing thyroidectomy for PTC. However, the absence of compelling evidence for a benefit in terms of recurrence or survival, and the potential for increased morbidity, have led many, including our institution, to take an approach of selective central lymph node dissection. This approach is guided by the detection of abnormal lymph nodes on preoperative ultrasound, on physical examination, or during surgery. Postoperatively, ultrasound by an experienced ultrasonographer is the mainstay of evaluation for lymph node recurrence and is combined with monitoring of thyroglobulin and antithyroglobulin antibody levels. Reoperative lymph node dissection is typically undertaken upon detection and fine needle aspiration (FNA) of involved lymph nodes 0.8 cm or greater in size.

Portable gamma camera guidance in sentinel lymph node biopsy: prospective observational study of consecutive cases.

PubMed

Peral Rubio, F; de La Riva, P; Moreno-Ramírez, D; Ferrándiz-Pulido, L

2015-06-01

Sentinel lymph node biopsy is the most important tool available for node staging in patients with melanoma. To analyze sentinel lymph node detection and dissection with radio guidance from a portable gamma camera. To assess the number of complications attributable to this biopsy technique. Prospective observational study of a consecutive series of patients undergoing radioguided sentinel lymph node biopsy. We analyzed agreement between nodes detected by presurgical lymphography, those detected by the gamma camera, and those finally dissected. A total of 29 patients (17 women [62.5%] and 12 men [37.5%]) were enrolled. The mean age was 52.6 years (range, 26-82 years). The sentinel node was dissected from all patients; secondary nodes were dissected from some. In 16 cases (55.2%), there was agreement between the number of nodes detected by lymphography, those detected by the gamma camera, and those finally dissected. The only complications observed were seromas (3.64%). No cases of wound dehiscence, infection, hematoma, or hemorrhage were observed. Portable gamma-camera radio guidance may be of use in improving the detection and dissection of sentinel lymph nodes and may also reduce complications. These goals are essential in a procedure whose purpose is melanoma staging. Copyright © 2014 Elsevier España, S.L.U. and AEDV. All rights reserved.

Clinicopathologic risk factors for right paraesophageal lymph node metastasis in patients with papillary thyroid carcinoma.

PubMed

Yu, Q A; Ma, D K; Liu, K P; Wang, P; Xie, C M; Wu, Y H; Dai, W J; Jiang, H C

2018-03-17

To investigate risk factors associated with right paraesophageal lymph node (RPELN) metastasis in patients with papillary thyroid carcinoma (PTC) and to determine the indications for right lymph node dissection. Clinicopathologic data from 829 patients (104 men and 725 women) with PTC, operated on by the same thyroid surgery team at the First Affiliated Hospital of Harbin Medical University from January 2013 to May 2017, were analyzed. Overall, 309 patients underwent total thyroidectomy with bilateral lymph node dissection, 488 underwent right thyroid lobe and isthmic resection with right central compartment lymph node dissection, and 32 underwent near-total thyroidectomy (ipsilateral thyroid lobectomy with contralateral near-total lobectomy) with bilateral lymph node dissection. The overall rate of central compartment lymph node metastasis was 43.5% (361/829), with right central compartment lymph node and RPELN metastasis rates of 35.5% (294/829) and 19.1% (158/829), respectively. Tumor size, number, invasion, and location, lymph node metastasis, right central compartment lymph node metastasis, and right lateral compartment lymph node metastasis were associated with RPELN in the univariate analysis, whereas age and sex were not. Multivariate analysis identified tumors with a diameter ≥ 1 cm, multiple tumors, tumors located in the right lobe, right central compartment lymph node metastasis, and right lateral compartment lymph node metastasis as independent risk factors for RPELN metastasis. Lymph node dissection, including RPELN dissection, should be performed for patients with PTC with a tumor diameter ≥ 1 cm, multiple tumors, right-lobe tumors, right central compartment lymph node metastasis, or suspected lateral compartment lymph node metastasis.

The surgical outcomes of robot-assisted laparoscopic pancreaticoduodenectomy versus laparoscopic pancreaticoduodenectomy for periampullary neoplasms: a comparative study of a single center.

PubMed

Liu, Rong; Zhang, Tao; Zhao, Zhi-Ming; Tan, Xiang-Long; Zhao, Guo-Dong; Zhang, Xuan; Xu, Yong

2017-06-01

Pancreaticoduodenectomy (PD) is a difficult and complex operation. The introduction of robotics has opened up new angles in pancreatic surgery. This study aims to assess the surgical outcomes of robot-assisted laparoscopic pancreaticoduodenectomy relative to its laparoscopic counterpart. A retrospective study was designed to compare the surgical outcomes of 27 robot-assisted laparoscopic pancreaticoduodenectomy (RPD) and 25 laparoscopic pancreaticoduodenectomy (LPD). Perioperative data, including operating time, complication, morbidity and mortality, estimated blood loss, and postoperative length of stay, were analyzed. The robotic group exhibited significantly shorter operative time (mean 387 vs. 442 min), shorter hospital stay (mean 17 vs. 24 days), and less blood loss (mean 219 vs. 334 ml) than those in the LPD group. No statistical difference was observed between the two groups in terms of complication rate, mortality rate, R0 resection rate, and number of harvested lymph node. RPD is more efficient and secure process than LPD among properly selected patients. RPD is therefore a feasible alternative to the laparoscopic procedure. Further studies are needed to evaluate the cost effectiveness of the robotic approach for PD.

Robot-assisted posterior retroperitoneoscopic adrenalectomy using single-port access: technical feasibility and preliminary results.

PubMed

Park, Jae Hyun; Kim, Soo Young; Lee, Cho-Rok; Park, Seulkee; Jeong, Jun Soo; Kang, Sang-Wook; Jeong, Jong Ju; Nam, Kee-Hyun; Chung, Woong Youn; Park, Cheong Soo

2013-08-01

Posterior retroperitoneoscopic adrenalectomy (PRA) has several benefits compared with transperitoneal adrenalectomy in that it is safe and has a short learning curve. In addition, it provides direct short access to the target organ, prevents irritation to the intraperitoneal space, and does not require retraction of adjacent organs.1 (-) 3 We have performed several cases of robot-assisted PRA using single-port access for small adrenal tumors. This multimedia article introduces the detailed methods and preliminary results of this procedure. Five patients underwent single-port robot-assisted PRA between March 2010 and June 2011 at our institution. During the procedure, patients were placed in a prone jackknife position with their hip joints bent at a right angle (Fig. 1). A 3 cm transverse skin incision was made just below the lowest tip of the 12th rib (Fig. 2), and the Glove port (Nelis, Kyung-gi, Korea) was placed through the skin incision while maintaining pneumoretroperitoneum (Fig. 3). CO2 was then insufflated to a pressure of 18 mm Hg to create an adequate working space. A 10 mm robotic camera with a 30-degree up view was placed at the center of the incision through the most cephalic portion of the Glove port. A Maryland dissector or Prograsp forceps (Intuitive Surgical, Inc., Sunnyvale, CA) was placed on the medial side of the incision, and Harmonic curved shears (Intuitive Surgical) were placed on the lateral side of the incision (Fig. 4). Using the Maryland dissector and the harmonic curved shears, the Gerota fascia is opened, perinephric fat is dissected, and the kidney upper pole is mobilized to expose the adrenal gland (Fig. 5). Gland dissection starts with lower margin detachment from the upper kidney pole in a lateral to medial direction (Fig. 6). After dissecting the adrenal gland from surrounding adipose tissue and medial isolation of the adrenal central vein, the vessel is ligated with a 5 mm hemolock clip (Fig. 7). Patient clinicopathologic data were analyzed retrospectively. The mean patient age was 56.6 ± 8.7 (range, 47-69) years. Right and left side approaches were used in two and three patients, respectively. All cases were adrenal cortical adenoma. The mean tumor size was 1.48 ± 0.28 (range, 1.0-1.7) cm. The mean surgery duration (skin to skin) was 159.4 ± 57.6 (range, 103-245) minutes, and the mean estimated blood loss was 46.0 ± 56.8 (range, 5-120) ml. The average time to oral intake and postoperative hospital stay were 0.65 ± 0.11 (range, 0.54-0.79) days and 4.0 ± 2.23 (range, 3-8) days, respectively. There were no conversions to open surgery or postoperative compli- cations. Some trials of minimally invasive single-access surgery of the adrenal gland have recently been performed.4 (,) 5 However, these new techniques have several limitations as a result of restrictions on instrumentation movement because of the small access ports used and relatively low-quality images produced. The recent introduction of the da Vinci S surgical robot system (Intuitive Surgical) to endoscopic surgery has improved instrumental dexterity and provided the surgeon with an ergonomically designed operating system. This system is also potentially safer and more meticulous in performing operations than endoscopic procedures as a result of a 3-D, magnified, stable operative view.6 (,) 7 The advantages of the da Vinci S surgical robot system and the numerous benefits of the posterior retroperitoneal approach motivated us to utilize single-port robot-assisted PRA. The primary selection criteria were small tumor size and a minimal amount of periadrenal fatty tissue because robot-assisted PRA using single-port access provides a small operative space, which causes manipulation problems when tumors are large. To ensure the safe application of these new techniques, we recommend that novice surgeons begin using single-port robot-assisted PRA for smaller tumors < 2 cm in patients with a body mass index of < 30 kg/m(2), gradually extending the size and body mass index as they accumulate experience. Although robot-assisted PRA using single-port access could not be compared with the other robotic adrenalectomy techniques in this study, the potential advantages of this approach compared to conventional robot-assisted transperitoneal adrenalectomy include a reduction in postoperative ileus, bacterial contamination, and intestinal complications because the peritoneal cavity is not opened, in addition to a reduction in postoperative pain because of its minimally invasive nature. Our initial experiences with robot-assisted PRA using single-port access assured us of its safety and feasibility for the resection of small adrenal tumors. Although single-port robot-assisted PRA appears to be safe and feasible, further experience and research is required to optimize patient selection criteria and verify its advantages over the traditional three-incision PRA technique.

[Comparison of robotic surgery with laparoscopy for surgical staging of endometrial cancer: a meta-analysis].

PubMed

Li, X M; Wang, J

2017-03-25

Objective: To evaluate the safety and effectiveness of robotic surgery in surgical staging of endometrial cancer. Methods: Searched English and Chinese databases, including Cochrane library, PubMed, Embase, Web of Science, China National Knowledge Internet, data base of Wanfang, China Science and Technology Journal (CSTJ) , and relevant journals and magazines by hand from Jan. 2000 to Oct. 2016. (1) In accordance with the inclusion criteria, two independent investigators screened databases and extracted the relevant data respectively, then evaluated the quality of including studies in Newcastle-Ottawa Scale (NOS) . (2) Meta-analysis was performed with RevMan 5.3 software. Heterogeneity inspection was done for each study and different effect model included the random effect model and fixed effect model was chose according to the results: of the inspection. At last, the related parameters of the robotic surgery and laparoscopic surgery was analysed. Results (1) Thirteen articles were ultimately included. All of them were written in English and included a total of 1 554 patients, included 739 cases of robotic surgery and 815 cases of laparoscopic surgery. Thirteen articles were all cohort study, four of them were prospective cohort study, while others were retrospective cohort study. After quality assessment, all studies had more than 5 stars and illustrated the higher quality. (2) Meta-analysis results showed: compared with laparoscopic surgery in surgical staging of endometrial cancer, robotic surgery had less estimated blood loss [standard deviation ( SD )=-72.31 ml, 95% CI :-107.29 to-37.33, P <0.01], less time for hospital stay ( SD =-0.29 days, 95% CI :-0.46 to-0.13, P =0.001), less need for blood transfusion [risk ratio ( RR )=0.57, 95% CI : 0.33 to 0.97, P =0.040], and conversion to open surgery ( RR =0.41, 95% CI : 0.26 to 0.65, P =0.000), less intraoperative complications ( RR =0.43, 95% CI : 0.24 to 0.76, P =0.004) in surgical staging of endometrial cancer. There was no statistically significant difference in aspects of operative time ( SD =10.26 minutes, 95% CI :-13.62 to 34.13, P =0.400), postoperative complications ( RR =0.87, 95% CI : 0.67 to 1.12, P =0.280), the total number of lymph nodes removed ( SD =-0.04, 95% CI :-3.99 to 3.91, P =0.980), the number of pelvic lymph node dissection ( SD =0.48, 95% CI :-1.76 to 2.71, P =0.680) and the number of para-aortic lymph node dissection ( SD =0.46, 95% CI :-1.42 to 2.34, P =0.630). Conclusions: Compared the robotic surgery with laparoscopic surgery in surgical staging of endometrial cancer, robotic surgery has less estimated blood loss, less need for blood transfusion and conversion to open surgery, less intraoperative complications and other advantages. While its cost is so expensive that restrict clinical application.

Radiotherapy or surgery of the axilla after a positive sentinel node in breast cancer (EORTC 10981-22023 AMAROS):a randomised, multicentre, open-label, phase 3 non-inferiority trial

PubMed Central

Donker, Mila; van Tienhoven, Geertjan; Straver, Marieke E; Meijnen, Philip; van de Velde, Cornelis J H; Mansel, Robert E; Cataliotti, Luigi; Westenberg, A Helen; Klinkenbijl, Jean H G; Orzalesi, Lorenzo; Bouma, Willem H; van der Mijle, Huub C J; Nieuwenhuijzen, Grard A P; Veltkamp, Sanne C; Slaets, Leen; Duez, Nicole J; de Graaf, Peter W; van Dalen, Thijs; Marinelli, Andreas; Rijna, Herman; Snoj, Marko; Bundred, Nigel J; Merkus, Jos W S; Belkacemi, Yazid; Petignat, Patrick; Schinagl, Dominic A X; Coens, Corneel; Messina, Carlo G M; Bogaerts, Jan; Rutgers, Emiel J T

2014-01-01

Summary Background If treatment of the axilla is indicated in patients with breast cancer who have a positive sentinel node, axillary lymph node dissection is the present standard. Although axillary lymph node dissection provides excellent regional control, it is associated with harmful side-effects. We aimed to assess whether axillary radiotherapy provides comparable regional control with fewer side-effects. Methods Patients with T1–2 primary breast cancer and no palpable lymphadenopathy were enrolled in the randomised, multicentre, open-label, phase 3 non-inferiority EORTC 10981-22023 AMAROS trial. Patients were randomly assigned (1:1) by a computer-generated allocation schedule to receive either axillary lymph node dissection or axillary radiotherapy in case of a positive sentinel node, stratified by institution. The primary endpoint was non-inferiority of 5-year axillary recurrence, considered to be not more than 4% for the axillary radiotherapy group compared with an expected 2% in the axillary lymph node dissection group. Analyses were by intention to treat and per protocol. The AMAROS trial is registered with ClinicalTrials.gov, number NCT00014612. Findings Between Feb 19, 2001, and April 29, 2010, 4823 patients were enrolled at 34 centres from nine European countries, of whom 4806 were eligible for randomisation. 2402 patients were randomly assigned to receive axillary lymph node dissection and 2404 to receive axillary radiotherapy. Of the 1425 patients with a positive sentinel node, 744 had been randomly assigned to axillary lymph node dissection and 681 to axillary radiotherapy; these patients constituted the intention-to-treat population. Median follow-up was 6·1 years (IQR 4·1–8·0) for the patients with positive sentinel lymph nodes. In the axillary lymph node dissection group, 220 (33%) of 672 patients who underwent axillary lymph node dissection had additional positive nodes. Axillary recurrence occurred in four of 744 patients in the axillary lymph node dissection group and seven of 681 in the axillary radiotherapy group. 5-year axillary recurrence was 0·43% (95% CI 0·00–0·92) after axillary lymph node dissection versus 1·19% (0·31–2·08) after axillary radiotherapy. The planned non-inferiority test was underpowered because of the low number of events. The one-sided 95% CI for the underpowered non-inferiority test on the hazard ratio was 0·00–5·27, with a non-inferiority margin of 2. Lymphoedema in the ipsilateral arm was noted significantly more often after axillary lymph node dissection than after axillary radiotherapy at 1 year, 3 years, and 5 years. Interpretation Axillary lymph node dissection and axillary radiotherapy after a positive sentinel node provide excellent and comparable axillary control for patients with T1–2 primary breast cancer and no palpable lymphadenopathy. Axillary radiotherapy results in significantly less morbidity. Funding EORTC Charitable Trust. PMID:25439688

Completion Dissection or Observation for Sentinel-Node Metastasis in Melanoma.

PubMed

Faries, Mark B; Thompson, John F; Cochran, Alistair J; Andtbacka, Robert H; Mozzillo, Nicola; Zager, Jonathan S; Jahkola, Tiina; Bowles, Tawnya L; Testori, Alessandro; Beitsch, Peter D; Hoekstra, Harald J; Moncrieff, Marc; Ingvar, Christian; Wouters, Michel W J M; Sabel, Michael S; Levine, Edward A; Agnese, Doreen; Henderson, Michael; Dummer, Reinhard; Rossi, Carlo R; Neves, Rogerio I; Trocha, Steven D; Wright, Frances; Byrd, David R; Matter, Maurice; Hsueh, Eddy; MacKenzie-Ross, Alastair; Johnson, Douglas B; Terheyden, Patrick; Berger, Adam C; Huston, Tara L; Wayne, Jeffrey D; Smithers, B Mark; Neuman, Heather B; Schneebaum, Schlomo; Gershenwald, Jeffrey E; Ariyan, Charlotte E; Desai, Darius C; Jacobs, Lisa; McMasters, Kelly M; Gesierich, Anja; Hersey, Peter; Bines, Steven D; Kane, John M; Barth, Richard J; McKinnon, Gregory; Farma, Jeffrey M; Schultz, Erwin; Vidal-Sicart, Sergi; Hoefer, Richard A; Lewis, James M; Scheri, Randall; Kelley, Mark C; Nieweg, Omgo E; Noyes, R Dirk; Hoon, Dave S B; Wang, He-Jing; Elashoff, David A; Elashoff, Robert M

2017-06-08

Sentinel-lymph-node biopsy is associated with increased melanoma-specific survival (i.e., survival until death from melanoma) among patients with node-positive intermediate-thickness melanomas (1.2 to 3.5 mm). The value of completion lymph-node dissection for patients with sentinel-node metastases is not clear. In an international trial, we randomly assigned patients with sentinel-node metastases detected by means of standard pathological assessment or a multimarker molecular assay to immediate completion lymph-node dissection (dissection group) or nodal observation with ultrasonography (observation group). The primary end point was melanoma-specific survival. Secondary end points included disease-free survival and the cumulative rate of nonsentinel-node metastasis. Immediate completion lymph-node dissection was not associated with increased melanoma-specific survival among 1934 patients with data that could be evaluated in an intention-to-treat analysis or among 1755 patients in the per-protocol analysis. In the per-protocol analysis, the mean (±SE) 3-year rate of melanoma-specific survival was similar in the dissection group and the observation group (86±1.3% and 86±1.2%, respectively; P=0.42 by the log-rank test) at a median follow-up of 43 months. The rate of disease-free survival was slightly higher in the dissection group than in the observation group (68±1.7% and 63±1.7%, respectively; P=0.05 by the log-rank test) at 3 years, based on an increased rate of disease control in the regional nodes at 3 years (92±1.0% vs. 77±1.5%; P<0.001 by the log-rank test); these results must be interpreted with caution. Nonsentinel-node metastases, identified in 11.5% of the patients in the dissection group, were a strong, independent prognostic factor for recurrence (hazard ratio, 1.78; P=0.005). Lymphedema was observed in 24.1% of the patients in the dissection group and in 6.3% of those in the observation group. Immediate completion lymph-node dissection increased the rate of regional disease control and provided prognostic information but did not increase melanoma-specific survival among patients with melanoma and sentinel-node metastases. (Funded by the National Cancer Institute and others; MSLT-II ClinicalTrials.gov number, NCT00297895 .).

[Application of central lymph node dissection to surgical operation for clinical stage n0 papillary thyroid carcinoma].

PubMed

Hu, Wei; Shi, Jun-Yi; Sheng, Yuan; Ll, Li

2008-03-01

The treatment for papillary thyroid carcinoma (PTC) without cervical lymph node metastasis (cN0) is controversial. This study was to explore a suitable method to dissect cervical lymph nodes for stage cN0 PTC patients. Eighty-four stage cN0 PTC patients, diagnosed by B ultrasound or cervical MRI from 2005--2006, were randomly divided into two groups. Thyroidectomy and ipsilateral central lymph node dissection were performed in Group A, while only thyroidectomy was performed in Group B. Each group contained 42 patients. Both groups took thyroxin tablets after operation. An average of 3 lymph nodes were found in each case of Group A, and the lymph node metastasis rate was 47.62%. The occurrence rates of complications were not significantly different between the two groups (P<0.05). Thyroidectomy plus ipsilateral central lymph node dissection is recommended for the treatment of stage cN0 PTC. It can also avoid damage of recurrent laryngeal nerve in re-dissection.

Sentinel node biopsy before neoadjuvant chemotherapy spares breast cancer patients axillary lymph node dissection.

PubMed

van Rijk, Maartje C; Nieweg, Omgo E; Rutgers, Emiel J T; Oldenburg, Hester S A; Olmos, Renato Valdés; Hoefnagel, Cornelis A; Kroon, Bin B R

2006-04-01

Neoadjuvant chemotherapy in breast cancer patients is a valuable method to determine the efficacy of chemotherapy and potentially downsize the primary tumor, which facilitates breast-conserving therapy. In 18 studies published about sentinel node biopsy after neoadjuvant chemotherapy, the sentinel node was identified in on average 89%, and the false-negative rate was on average 10%. Because of these mediocre results, no author dares to omit axillary clearance just yet. In our institute, sentinel lymph node biopsy is performed before neoadjuvant chemotherapy. The aim of this study was to evaluate our experience with this approach. Sentinel node biopsy was performed before neoadjuvant chemotherapy in 25 T2N0 patients by using lymphoscintigraphy, a gamma ray detection probe, and patent blue dye. Axillary lymph node dissection was performed after chemotherapy if the sentinel node contained metastases. Ten patients had a tumor-positive axillary sentinel node, and one patient had an involved lateral intramammary node. Four patients had additional involved nodes in the completion lymph node dissection specimen. The other 14 patients (56%) had a tumor-negative sentinel node and did not undergo axillary lymph node dissection. No recurrences have been observed after a median follow-up of 18 months. Fourteen (56%) of the 25 patients were spared axillary lymph node dissection when the sentinel node was found to be disease free. Performing sentinel node biopsy before neoadjuvant chemotherapy seems successful and reliable in patients with T2N0 breast cancer.

Video. Natural Orifice Translumenal Endoscopic Surgery with a miniature in vivo surgical robot.

PubMed

Lehman, Amy C; Dumpert, Jason; Wood, Nathan A; Visty, Abigail Q; Farritor, Shane M; Varnell, Brandon; Oleynikov, Dmitry

2009-07-01

The application of flexible endoscopy tools for Natural Orifice Translumenal Endoscopic Surgery (NOTES) is constrained due to limitations in dexterity, instrument insertion, navigation, visualization, and retraction. Miniature endolumenal robots can mitigate these constraints by providing a stable platform for visualization and dexterous manipulation. This video demonstrates the feasibility of using an endolumenal miniature robot to improve vision and to apply off-axis forces for task assistance in NOTES procedures. A two-armed miniature in vivo robot has been developed for NOTES. The robot is remotely controlled, has on-board cameras for guidance, and grasper and cautery end effectors for manipulation. Two basic configurations of the robot allow for flexibility during insertion and rigidity for visualization and tissue manipulation. Embedded magnets in the body of the robot and in an exterior surgical console are used for attaching the robot to the interior abdominal wall. This enables the surgeon to arbitrarily position the robot throughout a procedure. The visualization and task assistance capabilities of the miniature robot were demonstrated in a nonsurvivable NOTES procedure in a porcine model. An endoscope was used to create a transgastric incision and advance an overtube into the peritoneal cavity. The robot was then inserted through the overtube and into the peritoneal cavity using an endoscope. The surgeon successfully used the robot to explore the peritoneum and perform small-bowel dissection. This study has demonstrated the feasibility of inserting an endolumenal robot per os. Once deployed, the robot provided visualization and dexterous capabilities from multiple orientations. Further miniaturization and increased dexterity will enhance future capabilities.

Single-Port Surgery: Laboratory Experience with the daVinci Single-Site Platform

PubMed Central

Haber, Georges-Pascal; Kaouk, Jihad; Kroh, Matthew; Chalikonda, Sricharan; Falcone, Tommaso

2011-01-01

Background and Objectives: The purpose of this study was to evaluate the feasibility and validity of a dedicated da Vinci single-port platform in the porcine model in the performance of gynecologic surgery. Methods: This pilot study was conducted in 4 female pigs. All pigs had a general anesthetic and were placed in the supine and flank position. A 2-cm umbilical incision was made, through which a robotic single-port device was placed and pneumoperitoneum obtained. A data set was collected for each procedure and included port placement time, docking time, operative time, blood loss, and complications. Operative times were compared between cases and procedures by use of the Student t test. Results: A total of 28 surgical procedures (8 oophorectomies, 4 hysterectomies, 8 pelvic lymph node dissections, 4 aorto-caval nodal dissections, 2 bladder repairs, 1 uterine horn anastomosis, and 1 radical cystectomy) were performed. There was no statistically significant difference in operating times for symmetrical procedures among animals (P=0.3215). Conclusions: This animal study demonstrates that single-port robotic surgery using a dedicated single-site platform allows performing technically challenging procedures within acceptable operative times and without complications or insertion of additional trocars. PMID:21902962

[Correlation factors of lymph node metastasis in patients with clinical stage T1a non-small cell lung cancer].

PubMed

Ruochuan, Zang; Shugeng, Guo; Jie, He; Yousheng, Mao; Qi, Xue; Dali, Wang; Juwei, Mu; Jun, Zhao; Yonggang, Wang; Xiangyang, Liu; Fengwei, Tan; Gefei, Zhao; Qian, Zhang; Moyan, Zhang; Peng, Song

2015-04-01

To explore the relationship between the lymph node metastasis and clinicopathological features in patients with clinical stage T1a non-small cell lung cancer (NSCLC). Clinicopathological data of a total of 418 patients who underwent lobectomy and systematic lymph node dissection were retrospectively analyzed. Logistic regression was used to analyze the relationship between lymph node metastasis and clinicopathological features. Lymph node metastasis was observed in 25 patients. There were 122 patients who were diagnosed as ground glass opacity with no lymph node metastasis. 399 patients had subcarinal dissection, among them 7 patients were found to have lymph node metastasis. Univariate analysis showed that gender, smoking history, diameter of lymph node, ground glass opacity (GGO), differentiation of the tumor and tumor site were the factors affecting lymph node metastasis (all P < 0.05). Logistic regression analysis showed that diameter of lymph node, differentiation of the tumor and the site of lesion were independent risk factors for lymph node metastasis of NSCLC. Tumor in the left lung, poor differentiation, and diameter of lymph nodes ≥ 1 cm on the preoperative CT image are independent risk factors for lymph node metastasis of NSCLC, hence we should pay attention before surgery and systematic lymph node dissection should be done. For patients with poor differentiation and lymph nodes ≥ 1 cm, subcarinal lymph nodes dissection is recommended for the sake of higher possibility of lymph node metastasis. For patients with ground glass opacity ≤ 2 cm, the lymph node metastasis is extremely rare, therefore, selective lymph node dissection is reconmmended.

Study of the Navigation Method for a Snake Robot Based on the Kinematics Model with MEMS IMU.

PubMed

Zhao, Xu; Dou, Lihua; Su, Zhong; Liu, Ning

2018-03-16

A snake robot is a type of highly redundant mobile robot that significantly differs from a tracked robot, wheeled robot and legged robot. To address the issue of a snake robot performing self-localization in the application environment without assistant orientation, an autonomous navigation method is proposed based on the snake robot's motion characteristic constraints. The method realized the autonomous navigation of the snake robot with non-nodes and an external assistant using its own Micro-Electromechanical-Systems (MEMS) Inertial-Measurement-Unit (IMU). First, it studies the snake robot's motion characteristics, builds the kinematics model, and then analyses the motion constraint characteristics and motion error propagation properties. Second, it explores the snake robot's navigation layout, proposes a constraint criterion and the fixed relationship, and makes zero-state constraints based on the motion features and control modes of a snake robot. Finally, it realizes autonomous navigation positioning based on the Extended-Kalman-Filter (EKF) position estimation method under the constraints of its motion characteristics. With the self-developed snake robot, the test verifies the proposed method, and the position error is less than 5% of Total-Traveled-Distance (TDD). In a short-distance environment, this method is able to meet the requirements of a snake robot in order to perform autonomous navigation and positioning in traditional applications and can be extended to other familiar multi-link robots.

Development of a Patient-Based Model for Estimating Operative Times for Robot-Assisted Radical Prostatectomy.

PubMed

Huben, Neil; Hussein, Ahmed; May, Paul; Whittum, Michelle; Kraswowki, Collin; Ahmed, Youssef; Jing, Zhe; Khan, Hijab; Kim, Hyung; Schwaab, Thomas; Underwood Iii, Willie; Kauffman, Eric; Mohler, James L; Guru, Khurshid A

2018-04-10

To develop a methodology for predicting operative times for robot-assisted radical prostatectomy (RARP) using preoperative patient, disease, procedural and surgeon variables to facilitate operating room (OR) scheduling. The model included preoperative metrics: BMI, ASA score, clinical stage, National Comprehensive Cancer Network (NCCN) risk, prostate weight, nerve-sparing status, extent and laterality of lymph node dissection, and operating surgeon (6 surgeons were included in the study). A binary decision tree was fit using a conditional inference tree method to predict operative times. The variables most associated with operative time were determined using permutation tests. The data was split at the value of the variable that results in the largest difference in means for surgical time across the split. This process was repeated recursively on the resultant data. 1709 RARPs were included. The variable most strongly associated with operative time was the surgeon (surgeons 2 and 4 - 102 minutes shorter than surgeons 1, 3, 5, and 6, p<0.001). Among surgeons 2 and 4, BMI had the strongest association with surgical time (p<0.001). Among patients operated by surgeons 1, 3, 5 and 6, RARP time was again most strongly associated with the surgeon performing RARP. Surgeons 1, 3, and 6 were on average 76 minutes faster than surgeon 5 (p<0.001). The regression tree output in the form of box plots showed operative time median and ranges according to patient, disease, procedural and surgeon metrics. We developed a methodology that can predict operative times for RARP based on patient, disease and surgeon variables. This methodology can be utilized for quality control, facilitate OR scheduling and maximize OR efficiency.

The Effect of Lymph Node Dissection on the Survival of Patients With Operable Gastric Carcinoma.

PubMed

Mocellin, Simone

2016-10-01

What is the effect of different extents of lymph node dissection (D1, D2, and D3 lymphadenectomy) in patients affected with operable gastric carcinoma? Compared with D1 lymphadenectomy (the most conservative type of lymph node dissection), D2 lymphadenectomy (but not D3) is associated with better disease-specific survival, although a more extended dissection is burdened by a higher postoperative mortality rate.

The role of intraoperative ultrasound in small renal mass robotic enucleation.

PubMed

Gunelli, Roberta; Fiori, Massimo; Salaris, Cristiano; Salomone, Umberto; Urbinati, Marco; Vici, Alexia; Zenico, Teo; Bertocco, Mauro

2016-12-30

As a result of the growing evidence on tumor radical resection in literature, simple enucleation has become one of the best techniques associated to robotic surgery in the treatment of renal neoplasia, as it guarantees minimal invasiveness and the maximum sparing of renal tissue, facilitating the use of reduced or zero ischemia techniques during resection. The use of a robotic ultrasound probe represents a useful tool to detect and define tumor location, especially in poorly exophytic small renal mass. A total of 22 robotic enucleations were performed on < 3 cm renal neoplasias (PADUA score 18 Pz 6/7 e 4 Pz 8) using a 12-5 MHz robotic ultrasound probe (BK Drop-In 8826). Once kidney had been isolated from the adipose capsule at the site of the neoplasia (2), the exact position of the lesion could be easily identified in all cases (22/22), even for mostly endophytic lesions, thanks to the insertion of the ultrasound probe through the assistant port. Images were produced and visualized by the surgeon using the TilePro feature of the DaVinci surgical system for producing a picture-in-picture image on the console screen. The margins of resection were then marked with cautery, thus allowing for speedy anatomical dissection. This reduced the time of ischemia to 8 min (6-13) and facilitated the enucleation technique when performed without clamping the renal peduncle (6/22). No complications due to the use of the ultrasound probe were observed. The use of an intraoperative robotic ultrasound probe has allowed for easier identification of small, mostly endophytic neoplasias, better anatomical approach, shorter ischemic time, reduced risk of pseudocapsule rupture during dissection, and easier enucleation in cases performed without clamping. It is noteworthy that the use of intraoperative ultrasound probe allows mental reconstruction of the tumor through an accurate 3D vision of the hidden field during surgical dissection.

Robot-assisted radical cystectomy with intracorporeal neobladder diversion: The Karolinska experience.

PubMed

Collins, Justin W; Sooriakumaran, P; Sanchez-Salas, R; Ahonen, R; Nyberg, T; Wiklund, N P; Hosseini, A

2014-07-01

The aim of this report is to describe our surgical technique of totally intracorporeal robotic assisted radical cystectomy (RARC) with neobladder formation. Between December 2003 and March 2013, a total of 147 patients (118 male, 29 female) underwent totally intracorporeal RARC for urinary bladder cancer. We also performed a systematic search of Medline, Embase and PubMed databases using the terms RARC, robotic cystectomy, robot-assisted, totally intracorporeal RARC, intracorporeal neobladder, intracorporeal urinary diversion, oncological outcomes, functional outcomes, and complication rates. The mean age of our patients was 64 years (range 37-87). On surgical pathology 47% had pT1 or less disease, 27% had pT2, 16% had pT3 and 10% had pT4. The mean number of lymph nodes removed was 21 (range 0-60). 24% of patients had lymph node positive dAQ1isease. Positive surgical margins occurred in 6 cases (4%). Mean follow-up was 31 months (range 4-115 months). Two patients (1.4%) died within 90 days of their operation. Using Kaplan-Meier analysis, overall survival and cancer specific survival at 60 months was 68% and 69.6%, respectively. 80 patients (54%) received a continent diversion with totally intracorporeal neobladder formation. In the neobladder subgroup median total operating time was 420 minutes (range 265-760). Daytime continence and satisfactory sexual function or potency at 12 months ranged between 70-90% in both men and women. Our experience with totally intracorporeal RARC demonstrates acceptable oncological and functional outcomes that suggest this is a viable alternative to open radical cystectomy.

Robotics in endoscopy.

PubMed

Klibansky, David; Rothstein, Richard I

2012-09-01

The increasing complexity of intralumenal and emerging translumenal endoscopic procedures has created an opportunity to apply robotics in endoscopy. Computer-assisted or direct-drive robotic technology allows the triangulation of flexible tools through telemanipulation. The creation of new flexible operative platforms, along with other emerging technology such as nanobots and steerable capsules, can be transformational for endoscopic procedures. In this review, we cover some background information on the use of robotics in surgery and endoscopy, and review the emerging literature on platforms, capsules, and mini-robotic units. The development of techniques in advanced intralumenal endoscopy (endoscopic mucosal resection and endoscopic submucosal dissection) and translumenal endoscopic procedures (NOTES) has generated a number of novel platforms, flexible tools, and devices that can apply robotic principles to endoscopy. The development of a fully flexible endoscopic surgical toolkit will enable increasingly advanced procedures to be performed through natural orifices. The application of platforms and new flexible tools to the areas of advanced endoscopy and NOTES heralds the opportunity to employ useful robotic technology. Following the examples of the utility of robotics from the field of laparoscopic surgery, we can anticipate the emerging role of robotic technology in endoscopy.

The robotic Whipple: operative strategy and technical considerations.

PubMed

MacKenzie, Shawn; Kosari, Kambiz; Sielaff, Timothy; Johnson, Eric

2011-03-01

Advances in robotic surgery have allowed the frontiers of minimally invasive pancreatic surgery to expand. We present a step-by-step approach to the robotic Whipple procedure. The discussion includes port setting and robotic docking, kocherization and superior mesenteric vein identification, portal dissection, releasing the ligament of Treitz, uncinate dissection, and reconstruction. A brief report of our initial 2-year experience with the robotic Whipple procedure is also presented.

Endometrial cancer surgery costs: robot vs laparoscopy.

PubMed

Holtz, David O; Miroshnichenko, Gennady; Finnegan, Mark O; Chernick, Michael; Dunton, Charles J

2010-01-01

To compare surgical costs for endometrial cancer staging between robotic-assisted and traditional laparoscopic methods. Retrospective chart review from November 2005 to July 2006 (Canadian Task Force classification II-3). Non-university-affiliated teaching hospital. Thirty-three women with diagnosed endometrial cancer undergoing hysterectomy, bilateral salpingo-oophorectomy, and pelvic and paraaortic lymph node resection. Patients underwent either robotic or traditional laparoscopic surgery without randomization. Hospital cost data were obtained for operating room time, instrument use, and disposable items from hospital billing records and provided by the finance department. Separate overall hospital stay costs were also obtained. Mean operative costs were higher for robotic procedures ($3323 vs $2029; p<.001), due in part to longer operating room time ($1549 vs $1335; p=.03). The more significant cost difference was due to disposable instrumentation ($1755 vs $672; p<.001). Total hospital costs were also higher for robotic-assisted procedures ($5084 vs $ 3615; p=.002). Robotic surgery costs were significantly higher than traditional laparoscopy costs for staging of endometrial cancer in this small cohort of patients. Copyright (c) 2010 AAGL. Published by Elsevier Inc. All rights reserved.

Robotic hepatobiliary surgery: update on the current status.

PubMed

Carr, A D; Ali, M R; Khatri, V P

2013-10-01

An update on the current status of robotic hepatobiliary surgery based on a review of the available literature. A literature search was performed using the PubMed database with search phrases "robotic hepatectomy", "robotic liver resection", "robotic liver surgery", "robotic hepatobiliary surgery", and "robotic biliary reconstruction". We selected articles with high volume case series or case controlled series. As a result of our literature search we will focus on the 9 major articles on robotic liver resection (RLR) with 235 patients undergoing RLR for a total of 244 liver resections. In addition a brief update on robotic biliary reconstruction will also be presented based on the above articles and recent review articles. Indications for robotic liver resection included both benign (N.=72, 29.5%) and malignant disease (N.=172, 70.5%). The most common indication was colorectal liver metastasis (N.=87, 50.6%) and hepatocellular carcinoma (N.=57, 33%). The most common type of resection was subsegmental (N.=55, 22.5%), with a significant number of major hepatectomies (N.=80, 32.8%). Overall conversion rate was 7.8%, with majority converted to open (N.=18) and one converted to hand assisted. The overall complication rate was 11.8% (N.=29). No perioperative mortality was reported. Preliminary results show that robotic assisted laparoscopic hepatobiliary surgery has materialized as a new technique that combines the advantages of laparoscopy with the dissection, suturing and articulation of robotics. This more closely approximates open surgery. The preliminary data demonstrates that RLR can be applied in major hepatobiliary centers safely. Future comparative studies are needed to determine if this is of significant benefit over current open techniques.

Effect of Neoadjuvant Chemotherapy on Axillary Lymph Node Positivity and Numbers in Breast Cancer Cases.

PubMed

Uyan, Mikail; Koca, Bulent; Yuruker, Savas; Ozen, Necati

2016-01-01

The aim of this study is to compare the numbers of axillary lymph nodes (ALN) taken out by dissection between patients with breast cancer operated on after having neoadjuvant chemotherapy (NAC) treatment and otherswithout having neoadjuvant chemotherapy, and to investigate factors affecting lymph node positivity. A total of 49 patients operated due to advanced breast cancer after neoadjuvant chemotherapy and 144 patients with a similar stage of the cancer having primary surgical treatment without chemotherapy at the general surgery clinic of Ondokuz Mayis University Medicine Faculty between the dates 01.01.2006 and 31.10.2012 were included in the study. The total number of lymph nodes taken out by axillary dissection (ALND) was categorized as the number of positive lymph nodes and divided into <10 and ≥10. The variables to be compared were analysed using the program SPSS 15.0 with P<0.05 accepted as significant. Median number of dissected lymph nodes from the patient group having neoadjuvant chemotherapy was 16 (16-33) while it was 20 (5-55) without chemotherapy. The respective median numbers of positive lymph nodes were 5 ( 0-19) and 10 (0-51). In 8 out of 49 neoadjuvant chemotherapy patients (16.3%), the number of dissected lymph nodes was below 10, and it was below 10 in 17 out of 144 primary surgery patients. Differences in numbers of dissected total and positive lymph nodes between two groups were significant, but this was not the case for numbers of <10 lymph nodes. The number of dissected lymph nodes from the patients with breast cancer having neoadjuvant chemotherapy may be less than without chemotherapy. This may not always be attributed to an inadequate axillary dissection. More research to evaluate the numbers of positive lymph nodes are required in order to increase the reliability of staging in the patients with breast cancer undergoing neoadjuvant chemotherapy.

Laser robotically assisted nerve-sparing radical prostatectomy: a pilot study of technical feasibility in the canine model.

PubMed

Gianduzzo, Troy; Colombo, Jose R; Haber, Georges-Pascal; Hafron, Jason; Magi-Galluzzi, Cristina; Aron, Monish; Gill, Inderbir S; Kaouk, Jihad H

2008-08-05

To examine the feasibility of using laser energy during nerve-sparing robotically assisted radical prostatectomy (RARP), as the energy sources currently used for haemostasis in RARP adversely affect cavernous nerve function, while clips require application by a skilled assistant, but laser energy potentially allows precise dissection with minimal collateral tissue injury. We used laser-based RARP in 10 dogs, using the da Vinci S system (Intuitive Surgical, Sunnyvale, CA, USA) and a prototype robotic laser instrument. The potassium-titanyl-phosphate laser was used for dissection at 2-6 W, with intermittent use of the neodymium-doped yttrium-aluminium-garnet laser at 5 W for coagulating larger vessels. The peak intracavernosal pressure response to nerve stimulation was recorded as a percentage of mean arterial pressure (ICP%MAP) before and after RARP. Five dogs were killed immediately after RARP and five were maintained alive for 72 h; the haemoglobin and haematocrit levels were measured before and after RARP in the latter five dogs. All 10 procedures were performed solely using laser energy and no additional haemostatic manoeuvres. The median prostate excision time was 65 min. The ICP%MAP before and after RARP (median 98.5% and 77.0%, P = 0.12) were not significantly different; similarly, the respective haemoglobin (median 14.4 vs 12.6 g/dL, P = 0.06) and haematocrit levels (45.1% vs 40.2%, P = 0.06) were not significantly different. Two dogs had catheter-related complications and one had an anastomotic leak. There were no laser-related complications or postoperative haemorrhage. Laser RARP is feasible in dogs and further assessment is warranted.

Insight into the da Vinci® Xi - technical notes for single-docking left-sided colorectal procedures.

PubMed

Ngu, James Chi-Yong; Sim, Sarah; Yusof, Sulaiman; Ng, Chee-Yung; Wong, Andrew Siang-Yih

2017-12-01

The adoption of robot-assisted laparoscopic colorectal surgery has been hampered by issues with docking, operative duration, technical difficulties in multi-quadrant access, and cost. The da Vinci® Xi has been designed to overcome some of these limitations. We describe our experience with the system and offer technical insights to its application in left-sided colorectal procedures. Our initial series of left-sided robotic colorectal procedures was evaluated. Patient demographics and operative outcomes were recorded prospectively using a predefined database. Between March 2015 and April 2016, 54 cases of robot-assisted laparoscopic left-sided colorectal procedures were successfully completed with no cases of conversion. The majority were low anterior resections for colorectal malignancies. Using the da Vinci® Xi Surgical System, multi-quadrant surgery involving dissection from the splenic flexure to the pelvis was possible without redocking. The da Vinci® Xi simplifies the docking procedure and makes single-docking feasible for multi-quadrant left-sided colorectal procedures. Copyright © 2016 John Wiley & Sons, Ltd.

[Technical points of laparoscopic splenic hilar lymph node dissection--The original intention of CLASS-04 research design].

PubMed

Huang, Changming; Lin, Mi

2018-02-25

According to Japanese gastric cancer treatment guidelines, the standard operation for locally advanced upper third gastric cancer is the total gastrectomy with D2 lymphadenectomy, which includes the dissection of the splenic hilar lymph nodes. With the development of minimally invasive ideas and surgical techniques, laparoscopic spleen-preserving splenic hilar lymph node dissection is gradually accepted. It needs high technical requirements and should be carried out by surgeons with rich experience of open operation and skilled laparoscopic techniques. Based on being familiar with the anatomy of splenic hilum, we should choose a reasonable surgical approach and standardized operating procedure. A favorable left-sided approach is used to perform the laparoscopic spleen-preserving splenic hilar lymph node dissection in Department of Gastric Surgery, Fujian Medical University Union Hospital. This means that the membrane of the pancreas is separated at the superior border of the pancreatic tail in order to reach the posterior pancreatic space, revealing the end of the splenic vessels' trunk. The short gastric vessels are severed at their roots. This enables complete removal of the splenic hilar lymph nodes and stomach. At the same time, based on the rich clinical practice of laparoscopic gastric cancer surgery, we have summarized an effective operating procedure called Huang's three-step maneuver. The first step is the dissection of the lymph nodes in the inferior pole region of the spleen. The second step is the dissection of the lymph nodes in the trunk of splenic artery region. The third step is the dissection of the lymph nodes in the superior pole region of the spleen. It simplifies the procedure, reduces the difficulty of the operation, improves the efficiency of the operation, and ensures the safety of the operation. To further explore the safety of laparoscopic spleen-preserving splenic hilar lymph node dissection for locally advanced upper third gastric cancer, in 2016, we launched a multicenter phase II( trial of safety and feasibility of laparoscopic spleen-preserving No.10 lymph node dissection for locally advanced upper third gastric cancer (CLASS-04). Through the multicenter prospective study, we try to provide scientific theoretical basis and clinical experience for the promotion and application of the operation, and also to standardize and popularize the laparoscopic spleen-preserving splenic hilar lymph node dissection to promote its development. At present, the enrollment of the study has been completed, and the preliminary results also suggested that laparoscopic spleen-preserving No.10 lymph node dissection for locally advanced upper third gastric cancer was safe and feasible. We believe that with the improvement of standardized operation training system, the progress of laparoscopic technology and the promotion of Huang's three-step maneuver, laparoscopic spleen-preserving splenic hilar lymph node dissection will also become one of the standard treatments for locally advanced upper third gastric cancer.

Sampling versus systematic full lymphatic dissection in surgical treatment of non-small cell lung cancer.

PubMed

Koulaxouzidis, Georgios; Karagkiouzis, Grigorios; Konstantinou, Marios; Gkiozos, Ioannis; Syrigos, Konstantinos

2013-04-22

The extent of mediastinal lymph node assessment during surgery for non-small cell cancer remains controversial. Different techniques are used, ranging from simple visual inspection of the unopened mediastinum to an extended bilateral lymph node dissection. Furthermore, different terms are used to define these techniques. Sampling is the removal of one or more lymph nodes under the guidance of pre-operative findings. Systematic (full) nodal dissection is the removal of all mediastinal tissue containing the lymph nodes systematically within anatomical landmarks. A Medline search was conducted to identify articles in the English language that addressed the role of mediastinal lymph node resection in the treatment of non-small cell lung cancer. Opinions as to the reasons for favoring full lymphatic dissection include complete resection, improved nodal staging and better local control due to resection of undetected micrometastasis. Arguments against routine full lymphatic dissection are increased morbidity, increase in operative time, and lack of evidence of improved survival. For complete resection of non-small cell lung cancer, many authors recommend a systematic nodal dissection as the standard approach during surgery, and suggest that this provides both adequate nodal staging and guarantees complete resection. Whether extending the lymph node dissection influences survival or recurrence rate is still not known. There are valid arguments in favor in terms not only of an improved local control but also of an improved long-term survival. However, the impact of lymph node dissection on long-term survival should be further assessed by large-scale multicenter randomized trials.

Hybrid-type endoscopic thyroidectomy (HET: Tori's method) for differentiated thyroid carcinoma including invasion to the trachea.

PubMed

Tori, Masayuki

2014-03-01

Endoscopic thyroidectomy (ET) or robotic thyroidectomy is yet to be applied to thyroid carcinoma invasive to the trachea and to wide lymph node node metastasis. On the other hand, small-incision thyroidectomy lacks sufficient working space and clear vision. The author has newly developed hybrid-type endoscopic thyroidectomy (HET) to overcome these problems. From March 2011 to February 2012, HET was performed for 85 patients. Clinicopathologic characteristics were analyzed. To evaluate the superiority of HET for malignancy representatively, conventional lobectomy with central compartment node dissection (CCND) performed 1 year previously was compared with HET. In lobectomy and node dissection, a single skin incision (1.5 cm) is made above the clavicle, with a port incision (5 mm) made 3 cm below the clavicle. Then CCND is performed directly through the incision by lifting up the isthmus. To obtain sufficient working space for the lobectomy, the strap muscles are taped and pulled toward the head, then hung by the cradle. The thyroid lobe is retracted to the midline with a retractor, followed by isolation of the inferior laryngeal nerve and transection of the inferior thyroid vessels with the monitor of the scope. Lateral lymph nodes dissection can be performed at the same time, if necessary. In total thyroidectomy, the same procedure is performed at the opposite side. The scalpel can be used to shave through each incision in case of tracheal invasion. Of the 85 cases, 62 were malignant, involving papillary thyroid carcinoma (PTC), and 23 were benign. Total thyroidectomy was performed for 22 of the PTC cases and CCND for 49 of the cases. Shaving for tracheal invasion was performed for eight patients. No mortality, complications, recurrence, or metastasis was found 1-2 years after the operation. Compared with conventional thyroidectomy, HET was superior in blood loss, visual analog scale, and postoperative hospital stay. The author's method (Tori's method) might be less invasive, cosmetically excellent, and moreover, safe and feasible for differentiated thyroid carcinoma including invasion to the trachea.

Robot-assisted simple prostatectomy: multi-institutional outcomes for glands larger than 100 grams.

PubMed

Vora, Anup; Mittal, Sameer; Hwang, Jonathan; Bandi, Gaurav

2012-05-01

To present our experience with robot-assisted simple prostatectomy in patients with large gland adenoma (>100 g) that would not be amenable to transurethral treatments. From August 2009 to May 2011, 13 robot-assisted simple suprapubic prostatectomies were performed in patients with symptomatic large gland (>100 g) prostatomegaly on transrectal ultrasonography (mean 163 cc). Essential aspects of our technique include a transverse cystotomy just proximal to the prostatovesical junction and use of a robotic tenotomy grasper to aid in adenoma dissection. Mean operative time was 179 minutes (range 90-270 min), and mean estimated blood loss was 219 mL (range 50-500 mL). Mean hospital stay was 2.7 days (range 1-8 d), and the mean urethral catheterization time was 8.8 days (range 5-14 d). None of the patients needed blood transfusion. One patient had an intraoperative urinary leak after bladder closure that was managed with prolonged urethral catheterization (14 d). Histopathologic analysis confirmed benign prostatic hyperplasia (BPH) in all patients, and mean specimen weight on pathologic examination was 127 g (range 100-165 g). Mean follow-up duration was 7.2 months with all patients having a minimum of a 4-month follow-up. Significant improvements were noted in the International Prostate Symptom Score (preoperative vs postoperative 18.1 vs 5.3, p<0.001) and the maximum urine flow rate (preoperative vs postoperative 4.3 vs 19.1 mL/min, P<0.001). Minimally invasive robot-assisted simple prostatectomy is technically feasible in patients with large volume (>100 g) BPH and is associated with significant improvements in obstructive urinary symptoms. Surgeons with robotic expertise may consider using this approach for treatment of their patients with large volume BPH.

Robotics in general thoracic surgery procedures.

PubMed

Latif, M Jawad; Park, Bernard J

2017-01-01

The use of robotic technology in general thoracic surgical practice continues to expand across various institutions and at this point many major common thoracic surgical procedures have been successfully performed by general thoracic surgeons using the robotic technology. These procedures include lung resections, excision of mediastinal masses, esophagectomy and reconstruction for malignant and benign esophageal pathologies. The success of robotic technology can be attributed to highly magnified 3-D visualization, dexterity afforded by 7 degrees of freedom that allow difficult dissections in narrow fields and the ease of reproducibility once the initial set up and instruments become familiar to the surgeon. As the application of robotic technology trickle downs from major academic centers to community hospitals, it becomes imperative that its role, limitations, learning curve and financial impact are understood by the novice robotic surgeon. In this article, we share our experience as it relates to the setup, common pitfalls and long term results for more commonly performed robotic assisted lung and thymic resections using the 4 arm da Vinci Xi robotic platform (Intuitive Surgical, Inc., Sunnyvale, CA, USA) to help guide those who are interested in adopting this technology.

[The Role of Supraclavicular lymph node dissection in Breast Cancer Patients with Synchronous Ipsilateral Supraclavicular Lymph Node Metastasis].

PubMed

Zhang, W; Qi, X M; Chen, A X; Zhang, P; Cao, X C; Xiao, C H

2017-05-23

Objective: In this study, we evaluated the effect of supraclavicular lymph node dissection in breast cancer patients who presented with ipsilateral supraclavicular lymph node metastasis (ISLM) without distant metastasis. Methods: A total of 90 patients with synchronous ISLM without distant metastasis between 2000 and 2009 were retrospectively analyzed. Patients were retrospectively divided into two groups, namely supraclavicular lymph node dissection group(34 patients) and non-dissection group(56 patients), according to whether they underwentsupraclavicular lymph node dissection or not.The Kaplan-Meier method was applied to analyze the locoregional relapse free survival (LRFS) and overall survival(OS). Results: Median follow-upwas 85 months(range, 6 to 11 months). Local recurrence in 32 cases, 47 cases of distant metastasis, of which 25 patients were accompanied by both locoregional relapse and distant metastasis. Of the 32 patients with locoregional relapse, 11 patients were in the lymph node dissection group and 21 patients in the control group. Of the 47 patients with distant metastases, 17 were treated with lymph node dissection, 30 in the control group. Thirty-two patients died in the whole group and 16 patients underwentlymph node dissection and 16 patients didn't. There was no significant difference between the rate of 5-year LRFS and 5-year OS ( P =0.359, P =0.246). For patients of ER negative, the 5-year loco-regional relapse free survival rates were 63.7% and 43.3% in supraclavicular lymph node dissection group and control group, respectively. The 5-year overall survival rates were 52.1% and 52.3%, respectively, and there were no statistically significant differences ( P =0.118, P =0.951). For patients of PR negative, the 5-yearloco-regional relapse free rates were 59.8% and 46.2%, respectively, and the 5-year overall survival rates were 50.6% and 43.2%, respectively, and there was no significant difference between the two groups ( P =0.317, P =0.973). The 5-year recurrence-free survival rates of human epidermal growth factor receptor 2 (HER2)-positive patients were 61.2% and 48.0%( P =0.634), respectively, and the 5-year overall survival rates were 37.2% and 65.4%( P =0.032). Forty-seven patients suffered distant metastases and the 5-year metastases free survival rates were 37.3% and 38.5% in supraclavicular lymph node dissection group and control group, respectively. Conclusion: Supraclavicular lymph node dissection maybe an effective approach to improve the loco-regional control for the patients with ISLM, especially for ER negative and PR negative subtypes, but it might has adverseeffects for the patients with negative HER2 status.

Robot-assisted laparoscopic pyeloplasty: minimum 1-year follow-up

NASA Astrophysics Data System (ADS)

Patel, Vipul; Thaly, Rahul; Shah, Ketul

2007-02-01

Objectives: To evaluate the feasibility and efficacy of robotic-assisted laparoscopic pyeloplasty. Laparoscopic pyeloplasty has been shown to have a success rate comparable to that of the open surgical approach. However, the steep learning curve has hindered its acceptance into mainstream urologic practice. The introduction of robotic assistance provides advantages that have the potential to facilitate precise dissection and intracorporeal suturing. Methods: A total of 50 patients underwent robotic-assisted laparoscopic dismembered pyeloplasty. A four-trocar technique was used. Most patients were discharged home on day 1, with stent removal at 3 weeks. Patency of the ureteropelvic junction was assessed in all patients with mercaptotriglycylglycine Lasix renograms at 1, 3, 6, 9, and 12 months, then every 6 months for 1 year, and then yearly. Results: Each patient underwent a successful procedure without open conversion or transfusion. The average estimated blood loss was 40 ml. The operative time averaged 122 minutes (range 60 to 330) overall. Crossing vessels were present in 30% of the patients and were preserved in all cases. The time for the anastomosis averaged 20 minutes (range 10 to 100). Intraoperatively, no complications occurred. Postoperatively, the average hospital stay was 1.1 days. The stents were removed at an average of 20 days (range 14 to 28) postoperatively. The average follow-up was 11.7 months; at the last follow-up visit, each patient was doing well. Of the 50 patients, 48 underwent one or more renograms, demonstrating stable renal function, improved drainage, and no evidence of recurrent obstruction. Conclusions: Robotic-assisted laparoscopic pyeloplasty is a feasible technique for ureteropelvic junction reconstruction. The procedure provides a minimally invasive alternative with good short-term results.

Robotic kidney autotransplantation in a porcine model: a procedure-specific training platform for the simulation of robotic intracorporeal vascular anastomosis.

PubMed

Tiong, Ho Yee; Goh, Benjamin Yen Seow; Chiong, Edmund; Tan, Lincoln Guan Lim; Vathsala, Anatharaman

2018-03-31

Robotic-assisted kidney transplantation (RKT) with the Da Vinci (Intuitive, USA) platform has been recently developed to improve outcomes by decreasing surgical site complications and morbidity, especially in obese patients. This potential paradigm shift in the surgical technique of kidney transplantation is performed in only a few centers. For wider adoption of this high stake complex operation, we aimed to develop a procedure-specific simulation platform in a porcine model for the training of robotic intracorporeal vascular anastomosis and evaluating vascular anastomoses patency. This paper describes the requirements and steps developed for the above training purpose. Over a series of four animal ethics' approved experiments, the technique of robotic-assisted laparoscopic autotransplantation of the kidney was developed in Amsterdam live pigs (60-70 kg). The surgery was based around the vascular anastomosis technique described by Menon et al. This non-survival porcine training model is targeted at transplant surgeons with robotic surgery experience. Under general anesthesia, each pig was placed in lateral decubitus position with the placement of one robotic camera port, two robotic 8 mm ports and one assistant port. Robotic docking over the pig posteriorly was performed. The training platform involved the following procedural steps. First, ipsilateral iliac vessel dissection was performed. Second, robotic-assisted laparoscopic donor nephrectomy was performed with in situ perfusion of the kidney with cold Hartmann's solution prior to complete division of the hilar vessels, ureter and kidney mobilization. Thirdly, the kidney was either kept in situ for orthotopic autotransplantation or mobilized to the pelvis and orientated for the vascular anastomosis, which was performed end to end or end to side after vessel loop clamping of the iliac vessels, respectively, using 6/0 Gore-Tex sutures. Following autotransplantation and release of vessel loops, perfusion of the graft was assessed using intraoperative indocyanine green imaging and monitoring urine output after unclamping. This training platform demonstrates adequate face and content validity. With practice, arterial anastomotic time could be improved, showing its construct validity. This porcine training model can be useful in providing training for robotic intracorporeal vascular anastomosis and may facilitate confident translation into a transplant human recipient.

Retrograde renal hilar dissection and segmental arterial clamping: a simple modification to achieve super-selective robotic partial nephrectomy.

PubMed

Greene, Richard N; Sutherland, Douglas E; Tausch, Timothy J; Perez, Deo S

2014-03-01

Super-selective vascular control prior to robotic partial nephrectomy (also known as 'zero-ischemia') is a novel surgical technique that promises to reduce warm ischemia time. The technique has been shown to be feasible but adds substantial technical complexity and cost to the procedure. We present a simplified retrograde dissection of the renal hilum to achieve selective vascular control during robotic partial nephrectomy. Consecutive patients with stage 1 solid and complex cystic renal masses underwent robotic partial nephrectomies with selective vascular control using a modification to previously described super-selective robotic partial nephrectomy. In each case, the renal arterial branch supplying the mass and surrounding parenchyma was dissected in a retrograde fashion from the tumor. Intra-renal dissection of the interlobular artery was not performed. Intra-operative immunofluorescence was not utilized as assessment of parenchymal ischemia was documented before partial nephrectomy. Data was prospectively collected in an IRB-approved partial nephrectomy database. Operative variables between patients undergoing super-selective versus standard robotic partial nephrectomy were compared. Super-selective partial nephrectomy with retrograde hilar dissection was successfully completed in five consecutive patients. There were no complications or conversions to traditional partial nephrectomy. All were diagnosed with renal cell carcinoma and surgical margins were all negative. Estimated blood loss, warm ischemia time, operative time and length of stay were all comparable between patients undergoing super-selective and standard robotic partial nephrectomy. Retrograde hilar dissection appears to be a feasible and safe approach to super-selective partial nephrectomy without adding complex renovascular surgical techniques or cost to the procedure.

Robotic radical cystectomy and intracorporeal urinary diversion: The USC technique.

PubMed

Abreu, Andre Luis de Castro; Chopra, Sameer; Azhar, Raed A; Berger, Andre K; Miranda, Gus; Cai, Jie; Gill, Inderbir S; Aron, Monish; Desai, Mihir M

2014-07-01

Radical cystectomy is the gold-standard treatment for muscle-invasive and refractory nonmuscle-invasive bladder cancer. We describe our technique for robotic radical cystectomy (RRC) and intracorporeal urinary diversion (ICUD), that replicates open surgical principles, and present our preliminary results. Specific descriptions for preoperative planning, surgical technique, and postoperative care are provided. Demographics, perioperative and 30-day complications data were collected prospectively and retrospectively analyzed. Learning curve trends were analyzed individually for ileal conduits (IC) and neobladders (NB). SAS(®) Software Version 9.3 was used for statistical analyses with statistical significance set at P < 0.05. Between July 2010 and September 2013, RRC and lymph node dissection with ICUD were performed in 103 consecutive patients (orthotopic NB=46, IC 57). All procedures were completed robotically replicating the open surgical principles. The learning curve trends showed a significant reduction in hospital stay for both IC (11 vs. 6-day, P < 0.01) and orthotopic NB (13 vs. 7.5-day, P < 0.01) when comparing the first third of the cohort with the rest of the group. Overall median (range) operative time and estimated blood loss was 7 h (4.8-13) and 200 mL (50-1200), respectively. Within 30-day postoperatively, complications occurred in 61 (59%) patients, with the majority being low grade (n = 43), and no patient died. Median (range) nodes yield was 36 (0-106) and 4 (3.9%) specimens had positive surgical margins. Robotic radical cystectomy with totally ICUD is safe and feasible. It can be performed using the established open surgical principles with encouraging perioperative outcomes.

Repeat sentinel lymph node biopsy in patients with ipsilateral recurrent breast cancer after breast-conserving therapy and negative sentinel lymph node biopsy: a prospective study.

PubMed

Folli, Secondo; Falco, Giuseppe; Mingozzi, Matteo; Buggi, Federico; Curcio, Annalisa; Ferrari, Guglielmo; Taffurelli, Mario; Regolo, Lea; Nanni, Oriana

2016-04-01

Patients with ipsilateral breast tumor recurrence or new ipsilateral primary tumor after previous breast conservative surgery with negative sentinel lymph node biopsy need a new axillary staging procedure. However, the best surgical option, i.e. repeat sentinel lymph node biopsy or axillary lymph node dissection, is still debated. Purpose of the study is to assess the performance of repeat sentinel lymph node biopsy. In a multicenter study, lymph node biopsy completed by back-up axillary lymph node dissection was undertaken for ipsilateral breast tumor recurrence or new ipsilateral primary tumor. Tracer uptake was used to identify and isolate the sentinel lymph node during surgery, and it was classified after staining with hematoxylin and eosin and monoclonal anti-cytokeratin antibodies. Aside from negative predictive value, overall accuracy and false-negative rate of repeat sentinel lymph node biopsy were assessed. A multicenter, prospective study was conducted performing 30 repeat sentinel lymph node biopsy completed by back-up axillary lymph node dissection for ipsilateral breast tumor recurrence or new ipsilateral primary tumor in patients formerly treated with previous breast conservative surgery and negative sentinel lymph node biopsy. Negative predictive value, overall accuracy and false-negative rate of repeat sentinel lymph node biopsy were assessed. Sentinel lymph nodes were mapped in 27 patients out of 30 (90%). Aberrant drainage pathways were observed in one patient (3.7%). Tracer uptake was sufficient to identify and isolate the sentinel lymph node during surgery in 23 cases (76.6%); the patients in whom lymphoscintigraphy failed or no sentinel lymph nodes could be isolated underwent axillary lymph node dissection. The negative predictive value was 95.2%, the accuracy was 95.6% and the false-negative rate was 33%. Repeat sentinel lymph node biopsy is feasible and accurate, with a high negative predictive value. Patients with ipsilateral breast tumor recurrence or new ipsilateral primary tumor after previous breast conservative surgery and negative sentinel lymph node biopsy can be treated with repeat sentinel lymph node biopsy for the axillary staging and can be spared axillary dissection in case of absence of metastases. However, repeat sentinel lymph node biopsy may prove technically impracticable in about one quarter of cases and thus axillary lymph node dissection remains the only viable option in such instance.

Sentinel lymph node biopsy for early oral cancers: Westmead Hospital experience.

PubMed

Abdul-Razak, Muzib; Chung, Hsiang; Wong, Eva; Palme, Carsten; Veness, Michael; Farlow, David; Coleman, Hedley; Morgan, Gary

2017-01-01

Sentinel lymph node biopsy (SLNB) has become an alternative option to elective neck dissection (END) for early oral cavity squamous cell carcinoma (OCSCC) outside of Australia. We sought to assess the technical feasibility of SLNB and validate its accuracy against that of END in an Australian setting. We performed a prospective cohort study consisting of 30 consecutive patients with cT 1 - 2 N 0 OCSCC referred to the Head and Neck Cancer Service, Westmead Hospital, Sydney, between 2011 and 2014. All patients underwent SLNB followed by immediate selective neck dissection (levels I-III). A total of 30 patients were diagnosed with an early clinically node-negative OCSCC (seven cT1 and 23 cT2), with the majority located on the oral tongue. A median of three (range: 1-14) sentinel nodes were identified on lymphoscintigraphy, and all sentinel nodes were successfully retrieved, with 50% having a pathologically positive sentinel node. No false-negative sentinel nodes were identified using selective neck dissection as the gold standard. The negative predictive value (NPV) of SLNB was 100%, with 40% having a sentinel node identified outside the field of planned neck dissection on lymphoscintigraphy. Of these, one patient had a positive sentinel node outside of the ipsilateral supraomohyoid neck dissection template. SLNB for early OCSCC is technically feasible in an Australian setting. It has a high NPV and can potentially identify at-risk lymphatic basins outside the traditional selective neck dissection levels even in well-lateralized lesions. © 2016 Royal Australasian College of Surgeons.

Relationship between intraprostatic tracer deposits and sentinel lymph node mapping in prostate cancer patients.

PubMed

Buckle, Tessa; Brouwer, Oscar R; Valdés Olmos, Renato A; van der Poel, Henk G; van Leeuwen, Fijs W B

2012-07-01

Intraprostatic injection of the hybrid tracer indocyanine green (ICG)-(99m)Tc-nanocolloid enables both preoperative sentinel node (SN) identification and intraoperative visualization of the SN. Relating the fluorescence deposits in embedded prostate tissue specimens to the preoperatively detected SNs also provides the opportunity to study the influence of their placement on lymphatic drainage pattern. Nineteen patients with prostate carcinoma scheduled for robot-assisted laparoscopic prostatectomy and lymph node (LN) dissection were included. ICG-(99m)Tc-nanocolloid was injected intraprostatically, guided by ultrasound. SN biopsy was performed using a combination of radioguidance and fluorescence guidance. Tracer distribution was visualized in paraffin-embedded prostate samples using ex vivo fluorescence imaging. This distribution was correlated to the number and location of the SNs identified on preoperative lymphoscintigraphy and SPECT/CT. ICG-(99m)Tc-nanocolloid helped guide surgical excision of the SNs. Ex vivo fluorescence imaging revealed a large variation in the locations of intraprostatic tracer deposits among patients. Tracer deposits in the peripheral zone correlated with a higher number of visualized LNs than deposits in the central zone (on average, 4.7 vs. 2.4 LNs per patient). Furthermore, tracer deposits in the mid gland correlated with a higher number of visualized LNs than deposits near the base or apex of the prostate (on average, 6 vs. 3.5 LNs per patient). The hybrid nature of the tracer not only enables surgical guidance but also provides an opportunity to study the correlation between the location of tracer deposits within the prostate and the number and location of preoperatively visualized SNs. These data suggest that the location at which a tracer deposit is placed influences the lymphatic drainage pattern.

Subcarinal lymph node in upper lobe non-small cell lung cancer patients: is selective lymph node dissection valid?

PubMed

Aokage, Keiju; Yoshida, Junji; Ishii, Genichiro; Hishida, Tomoyuki; Nishimura, Mitsuyo; Nagai, Kanji

2010-11-01

Little is known about selective lymph node dissection in non-small cell lung cancer (NSCLC) patients. We sought to gain insight into subcarinal node involvement for its frequency and impact on outcome to evaluate whether it is valid to omit subcarinal lymph node dissection in upper lobe NSCLC patients. We reviewed node metastases distribution according to node region, tumor location, and histology among 1099 patients with upper lobe NSCLC. We paid special attention to subcarinal metastases patients without superior mediastinal node metastases, because their pathological stages would have been underdiagnosed if subcarinal node dissection had been omitted. We also assessed the outcome and the pattern of failure among subcarinal metastases patients. To identify subcarinal node involvement predictors, we analyzed 7 clinical factors. Subcarinal node metastases were found in 20 patients and were least frequent among squamous cell carcinoma patients (0.5%). Two of them were free from superior mediastinal metastases but died of the disease at 1 month and due to an unknown cause at 18 months, respectively. Seventeen of the 20 patients developed multi-site recurrence within 37 months. The 5-year survival rate of the 20 patients with subcarinal metastases was 9.0%, which was significantly lower than 32.0% of patients with only superior mediastinal metastases. Clinical diagnosis of node metastases was significantly predictive of subcarinal metastases. Subcarinal node metastases from upper lobe NSCLC were rare and predicted an extremely poor outcome. It appears valid to omit subcarinal node dissection in upper lobe NSCLC patients, especially in clinical N0 squamous cell carcinoma patients. Copyright © 2010 Elsevier Ireland Ltd. All rights reserved.

Lymph Node Yield as a Predictor of Survival in Pathologically Node Negative Oral Cavity Carcinoma.

PubMed

Lemieux, Aaron; Kedarisetty, Suraj; Raju, Sharat; Orosco, Ryan; Coffey, Charles

2016-03-01

Even after a pathologically node-negative (pN0) neck dissection for oral cavity squamous cell carcinoma (SCC), patients may develop regional recurrence. In this study, we (1) hypothesize that an increased number of lymph nodes removed (lymph node yield) in patients with pN0 oral SCC predicts improved survival and (2) explore predictors of survival in these patients using a multivariable model. Case series with chart review. Administrative database analysis. The SEER database was queried for patients diagnosed with all-stage oral cavity SCC between 1988 and 2009 who were determined to be pN0 after elective lymph node dissection. Demographic and treatment variables were extracted. The association of lymph node yield with 5-year all-cause survival was studied with multivariable survival analyses. A total of 4341 patients with pN0 oral SCC were included in this study. The 2 highest lymph node yield quartiles (representing >22 nodes removed) were found to be significant predictors of overall survival (22-35 nodes: hazard ratio [HR] = 0.854, P = .031; 36-98 nodes: HR = 0.827, P = .010). Each additional lymph node removed during neck dissection was associated with increased survival (HR = 0.995, P = .022). These data suggest that patients with oral SCC undergoing elective neck dissection may experience an overall survival benefit associated with greater lymph node yield. Mechanisms behind the demonstrated survival advantage are unknown. Larger nodal dissections may remove a greater burden of microscopic metastatic disease, diminishing the likelihood of recurrence. Lymph node yield may serve as an objective measure of the adequacy of lymphadenectomy. © American Academy of Otolaryngology—Head and Neck Surgery Foundation 2015.

Potential role for carbon nanoparticles to guide central neck dissection in patients with papillary thyroid cancer.

PubMed

Yu, Wenbin; Cao, XiaoLi; Xu, Guihu; Song, Yuntao; Li, Guojun; Zheng, Hongliang; Zhang, Naisong

2016-09-01

The purpose of this study was to investigate the use and clinical utility of carbon nanoparticles as a lymph node tracer in the central neck lymph node dissection of patients with papillary thyroid cancer. One hundred forty consecutive patients were divided into a carbon nanoparticle group (n = 70) and a control group (n = 70). All patients underwent total or near-total thyroidectomy with bilateral central neck dissection. The carbon nanoparticle and control groups had different rates of metastatic lymph nodes (P = .017), total detected numbers of lymph nodes (P = .0001), total numbers of dissected lymph nodes <5 mm (P = .0001), and numbers of metastatic lymph nodes <5 mm (P = .0001). Of the 682 lymph nodes dissected in the carbon nanoparticle group, 579 (85%) were stained black, and of these, 147 (25%) were metastatic lymph nodes. There were 63 metastatic lymph nodes <5 mm among the black-stained metastatic lymph nodes, while there were 12 non-black-stained metastatic lymph nodes <5 mm. Of the total number of metastatic lymph nodes (n = 193), 147 (76%) were stained black. Moreover, pathologic results revealed that 5 accidental parathyroid resections occurred in the carbon nanoparticle group, compared with 14 in the control group (P = .046). Carbon nanoparticles might help to detect lymph nodes and increase the number of metastatic lymph nodes visualized and preserved. Therefore, use of carbon nanoparticles may reflect the metastatic condition of the central neck and have the potential to protect parathyroid glands. Copyright © 2016 Elsevier Inc. All rights reserved.

Clinical outcomes in endometrial cancer care when the standard of care shifts from open surgery to robotics.

PubMed

Mok, Zhun Wei; Yong, Eu Leong; Low, Jeffrey Jen Hui; Ng, Joseph Soon Yau

2012-06-01

In Singapore, the standard of care for endometrial cancer staging remains laparotomy. Since the introduction of gynecologic robotic surgery, there have been more data comparing robotic surgery to laparoscopy in the management of endometrial cancer. This study reviewed clinical outcomes in endometrial cancer in a program that moved from laparotomy to robotic surgery. A retrospective review was performed on 124 consecutive endometrial cancer patients. Preoperative data and postoperative outcomes of 34 patients undergoing robotic surgical staging were compared with 90 patients who underwent open endometrial cancer staging during the same period and in the year before the introduction of robotics. There were no significant differences in the mean age, body mass index, rates of diabetes, hypertension, previous surgery, parity, medical conditions, size of specimens, histologic type, or stage of cancer between the robotic and the open surgery groups. The first 20 robotic-assisted cases had a mean (SD) operative time of 196 (60) minutes, and the next 14 cases had a mean time of 124 (64) minutes comparable to that for open surgery. The mean number of lymph nodes retrieved during robot-assisted staging was smaller than open laparotomy in the first 20 cases but not significantly different for the subsequent 14 cases. Robot-assisted surgery was associated with lower intraoperative blood loss (110 [24] vs 250 [83] mL, P < 0.05), a lower rate of postoperative complications (8.8% vs 26.8%, P = 0.032), a lower wound complication rate (0% vs 9.9%, P = 0.044), a decreased requirement for postoperative parenteral analgesia (5.9% vs 51.1, P < 0.001), and shorter length of hospitalization (2.0 [1.1] vs 6.0 [4.5] days, P < 0.001) compared to patients in the open laparotomy group. Our series shows that outcomes traditionally associated with laparoscopic endometrial cancer staging are achievable by laparoscopy-naive gynecologic cancer surgeons moving from laparotomy to robot-assisted endometrial cancer staging after a relatively small number of cases.

A study of using carbon nanoparticles to improve lymph nodes staging for laparoscopic-assisted radical right hemicolectomy in colon cancer.

PubMed

Pan, Lelin; Ye, Feng; Liu, Jing-Jing; Ba, Xiao-Qun; Sheng, Qin-Song

2018-04-16

This study aimed to analyze and evaluate the feasibility of using carbon nanoparticles (CNs) to track lymph nodes (LNs) metastases in right colon tumors, especially for patients who underwent laparoscopic-assisted radical right hemicolectomy. A total of 99 patients were enrolled in this retrospective study between November 2015 and September 2017 (control group n = 47). One day before surgery, 1 ml of CNs suspension was injected into the submucosal layer around the site of the primary lesions by colonoscopy. Then complete mesocolic excision (CME) of laparoscopic right hemicolectomy was performed. CNs-stained LNs were identified and counted from all dissected LNs after surgery. The dates showed that the number of total harvested LNs and the number of positive patients in the experimental group increased significantly compared with the control group (respectively, P < 0.01 and P < 0.05). The increase of positive percentage shifted some patients toward higher stage, although the total number of positive LNs changed a little bit. In addition, the duration for pathologist to dissect LNs became shorter (26.4 vs. 31.1 min, P < 0.05). Therefore, the CNs are not only a good tattoo in laparoscopic-assisted operation, but could be regarded as a better pathological evaluating tool for tumor treatment.

da Vinci robot-assisted keyhole neurosurgery: a cadaver study on feasibility and safety.

PubMed

Marcus, Hani J; Hughes-Hallett, Archie; Cundy, Thomas P; Yang, Guang-Zhong; Darzi, Ara; Nandi, Dipankar

2015-04-01

The goal of this cadaver study was to evaluate the feasibility and safety of da Vinci robot-assisted keyhole neurosurgery. Several keyhole craniotomies were fashioned including supraorbital subfrontal, retrosigmoid and supracerebellar infratentorial. In each case, a simple durotomy was performed, and the flap was retracted. The da Vinci surgical system was then used to perform arachnoid dissection towards the deep-seated intracranial cisterns. It was not possible to simultaneously pass the 12-mm endoscope and instruments through the keyhole craniotomy in any of the approaches performed, limiting visualization. The articulated instruments provided greater dexterity than existing tools, but the instrument arms could not be placed in parallel through the keyhole craniotomy and, therefore, could not be advanced to the deep cisterns without significant clashing. The da Vinci console offered considerable ergonomic advantages over the existing operating room arrangement, allowing the operating surgeon to remain non-sterile and seated comfortably throughout the procedure. However, the lack of haptic feedback was a notable limitation. In conclusion, while robotic platforms have the potential to greatly enhance the performance of transcranial approaches, there is strong justification for research into next-generation robots, better suited to keyhole neurosurgery.

Regional lymph node staging in breast cancer: the increasing role of imaging and ultrasound-guided axillary lymph node fine needle aspiration.

PubMed

Mainiero, Martha B

2010-09-01

The status of axillary lymph nodes is a key prognostic indicator in patients with breast cancer and helps guide patient management. Sentinel lymph node biopsy is increasingly being used as a less morbid alternative to axillary lymph node dissection. However, when sentinel lymph node biopsy is positive, axillary dissection is typically performed for complete staging and local control. Axillary ultrasound and ultrasound-guided fine needle aspiration (USFNA) are useful for detecting axillary nodal metastasis preoperatively and can spare patients sentinel node biopsy, because those with positive cytology on USFNA can proceed directly to axillary dissection or neoadjuvant chemotherapy. Internal mammary nodes are not routinely evaluated, but when the appearance of these nodes is abnormal on imaging, further treatment or metastatic evaluation may be necessary. Copyright © 2010 Elsevier Inc. All rights reserved.

Study of the Navigation Method for a Snake Robot Based on the Kinematics Model with MEMS IMU

PubMed Central

Dou, Lihua; Su, Zhong; Liu, Ning

2018-01-01

A snake robot is a type of highly redundant mobile robot that significantly differs from a tracked robot, wheeled robot and legged robot. To address the issue of a snake robot performing self-localization in the application environment without assistant orientation, an autonomous navigation method is proposed based on the snake robot’s motion characteristic constraints. The method realized the autonomous navigation of the snake robot with non-nodes and an external assistant using its own Micro-Electromechanical-Systems (MEMS) Inertial-Measurement-Unit (IMU). First, it studies the snake robot’s motion characteristics, builds the kinematics model, and then analyses the motion constraint characteristics and motion error propagation properties. Second, it explores the snake robot’s navigation layout, proposes a constraint criterion and the fixed relationship, and makes zero-state constraints based on the motion features and control modes of a snake robot. Finally, it realizes autonomous navigation positioning based on the Extended-Kalman-Filter (EKF) position estimation method under the constraints of its motion characteristics. With the self-developed snake robot, the test verifies the proposed method, and the position error is less than 5% of Total-Traveled-Distance (TDD). In a short-distance environment, this method is able to meet the requirements of a snake robot in order to perform autonomous navigation and positioning in traditional applications and can be extended to other familiar multi-link robots. PMID:29547515

Complications following recurrent laryngeal nerve lymph node dissection in oesophageal cancer surgery.

PubMed

Taniyama, Yusuke; Miyata, Go; Kamei, Takashi; Nakano, Toru; Abe, Shigeo; Katsura, Kazunori; Sakurai, Tadashi; Teshima, Jin; Hikage, Makoto; Ohuchi, Norikaki

2015-01-01

The recurrent laryngeal nerve lymph node is one of the most common metastatic sites in oesophageal cancer, and dissection of this lymph node is considered beneficial. Although the risk of complications from this procedure, such as recurrent laryngeal nerve palsy, is well known, few reports have detailed those risks in a large number of cases. Our study examined the risks of recurrent laryngeal nerve lymph node dissection, with a special focus on recurrent laryngeal nerve palsy. Retrospectively collected data from 661 patients, who underwent transthoracic oesophagectomy for oesophageal cancer, were analysed. Recurrent laryngeal nerve palsy occurred in 36% of the patients. Among these patients, except those in whom recurrent laryngeal nerve was intentionally excised due to metastatic lymph node, permanent palsy was detected in 12%. Bilateral recurrent laryngeal nerve lymph node dissection, cervical anastomosis and upper oesophageal cancer were independent risk factors for recurrent laryngeal nerve palsy. Although recurrent laryngeal nerve palsy was a risk factor for aspiration, tracheostomy and postoperative pneumonia, it did not directly correlate with death caused by pneumonia. Among postoperative complications, only recurrent laryngeal nerve palsy correlated with bilateral recurrent laryngeal nerve lymph node dissection. Recurrent laryngeal nerve palsy is a complication that should be avoided but does not seem to be severe enough to affect patient survival after surgery. Although bilateral recurrent laryngeal nerve lymph node dissection can induce recurrent laryngeal nerve palsy in patients who undergo transthoracic oesophagectomy, this procedure did not correlate with aspiration and pneumonia. © The Author 2014. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.

Robotic-assisted single-port donor nephrectomy using the da Vinci single-site platform.

PubMed

LaMattina, John C; Alvarez-Casas, Josue; Lu, Irene; Powell, Jessica M; Sultan, Samuel; Phelan, Michael W; Barth, Rolf N

2018-02-01

Although single-port donor nephrectomy offers improved cosmetic outcomes, technical challenges have limited its application to selected centers. Our center has performed over 400 single-port donor nephrectomies. The da Vinci single-site robotic platform was utilized in an effort to overcome the steric, visualization, ergonomic, and other technical limitations associated with the single-port approach. Food and Drug Administration device exemption was obtained. Selection criteria for kidney donation included body mass index <35, left kidney donors, and ≤2 renal arteries. After colonic mobilization using standard single-port techniques, the robotic approach was utilized for ureteral complex and hilar dissection. Three cases were performed using the robotic single-site platform. Average total operative time was 262 ± 42 min including 82 ± 16 min of robotic use. Docking time took 20 ± 10 min. Blood loss averaged 77 ± 64 mL. No intraoperative complications occurred, and all procedures were completed with our standard laparoscopic single-port approach. This is the first clinical experience of robotic-assisted donor nephrectomy utilizing the da Vinci single-site platform. Our experience supported the safety of this approach but found that the technology added cost and complexity without tangible benefit. Development of articulating instruments, energy, and stapling devices will be necessary for increased application of robotic single-site surgery for donor nephrectomy. Copyright © 2017 Elsevier Inc. All rights reserved.

Occult lymph node metastasis and risk of regional recurrence in papillary thyroid cancer after bilateral prophylactic central neck dissection: A multi-institutional study.

PubMed

Lee, Young Chan; Na, Se Young; Park, Gi Cheol; Han, Ju Hyun; Kim, Seung Woo; Eun, Young Gyu

2017-02-01

The impact of occult lymph node metastasis on regional recurrence after prophylactic central neck dissection for preoperative, nodal-negative papillary thyroid cancer is controversial. We investigated risk factors for regional lymph node recurrence in papillary thyroid cancer patients who underwent total thyroidectomy and bilateral prophylactic central neck dissection. Analysis was according to clinicopathologic characteristics and occult lymph node metastasis patterns. This multicenter study enrolled 211 consecutive patients who underwent total thyroidectomy with bilateral prophylactic central neck dissection for papillary thyroid cancer without evidence of central lymph node metastasis on preoperative imaging. Clinicopathologic features and central lymph node metastasis patterns were analyzed for predicting regional recurrence. Multivariate Cox regression analysis was used to identify independent factors for recurrence. Median follow-up time was 43 months (24-95 months). Ten patients (4.7%) showed regional lymph node recurrence. The estimated 5-year, regional recurrence-free survival was 95.2%. Tumor size ≥1 cm, central lymph node metastasis, lymph node ratio, and prelaryngeal lymph node metastasis were associated with regional recurrence in univariate analysis (P < .05). In multivariate analysis, a lymph node ratio ≥ 0.26 was a significant risk factor for regional lymph node recurrence (odds ratio = 11.63, P = .003). Lymph node ratio ≥ 0.26 was an independent predictor of worse recurrence-free survival on Cox regression analysis (hazard ratio = 11.49, P = .002). Although no significant association was observed between the presence of occult lymph node metastasis and regional recurrence, lymph node ratio ≥ 0.26 was an independent predictor of regional lymph node recurrence in papillary thyroid cancer patients who underwent total thyroidectomy and bilateral prophylactic central neck dissection. Copyright © 2016 Elsevier Inc. All rights reserved.

Laparoscopic treatment of rectal cancer and lateral pelvic lymph node dissection. Are they obsolete?

PubMed

Toda, Shigeo; Kuroyanagi, Hiroya; Matoba, Shuichiro; Hiramatsu, Kosuke; Okazaki, Naoto; Tate, Tomohiro; Tomizawa, Kenji; Hanaoka, Yutaka; Moriyama, Jin

2018-05-24

Laparoscopic surgery for rectal cancer offers favorable short term results without compromising long term oncological outcomes so far, according to the data from major trials. Therefore it is being considered as a standard option for rectal cancer surgery. The learning curve of laparoscopic rectal cancer surgery is generally longer compared to colon cancer. Appropriate standardization and training of laparoscopic rectal cancer surgery is required. Several RCTs suggested the potential negative effect on quality of resected specimen, which can increase local recurrence. The long term outcomes especially local recurrence rate of these RCTs are awaited. Lateral pelvic lymph node dissection (LPLND) has a certain effect of reducing local recurrence of rectal cancer even after neoadjuvant radiotherapy. Since LPLND is associated with postoperative morbidity, we should carefully select the candidate to maximize the effect of LPLND and minimize the morbidity caused by LPLND. Recent advancement in imaging study such as CT and MRI enables us to find the suitable candidates for LPLND. The morbidity caused by LPLND could be reduced by minimally invasive surgeries such as laparoscopic surgery and robotic surgery. We have to improve oncological outcomes and reduce morbidity by the multidisciplinary strategy for rectal cancer including total mesorectal excision, neoadjuvant chemoradiotherapy and LPLND together with laparoscopic surgery.

Superficial and deep lymph node dissection for stage III cutaneous melanoma: clinical outcome and prognostic factors

PubMed Central

2013-01-01

Background The aims of this retrospective analysis were to evaluate the effect of combined superficial and deep groin dissection on disease-free and melanoma-specific survival, and to identify the most important factors for predicting the involvement of deep nodes according to clinically or microscopically detected nodal metastases. Methods Between January 1996 and December 2005, 133 consecutive patients with groin lymph node metastases underwent superficial and deep dissection at the National Cancer Institute, Naples. Lymph node involvement was clinically evident in 84 patients and detected by sentinel node biopsy in 49 cases. Results The 5-year disease-free survival was significantly better for patients with superficial lymph node metastases than for patients with involvement of both superficial and deep lymph nodes (34.9% vs. 19.0%; P = 0.001). The 5-year melanoma-specific survival was also significantly better for patients with superficial node metastases only (55.6% vs. 33.3%; P = 0.001). Conclusions Metastasis in the deep nodes is the strongest predictor of both disease-free and melanoma-specific survival. Deep groin dissection should be considered for all patients with groin clinical nodal involvement, but might be spared in patients with a positive sentinel node. Prospective studies will clarify the issue further. PMID:23379355

Superficial and deep lymph node dissection for stage III cutaneous melanoma: clinical outcome and prognostic factors.

PubMed

Mozzillo, Nicola; Caracò, Corrado; Marone, Ugo; Di Monta, Gianluca; Crispo, Anna; Botti, Gerardo; Montella, Maurizio; Ascierto, Paolo Antonio

2013-02-04

The aims of this retrospective analysis were to evaluate the effect of combined superficial and deep groin dissection on disease-free and melanoma-specific survival, and to identify the most important factors for predicting the involvement of deep nodes according to clinically or microscopically detected nodal metastases. Between January 1996 and December 2005, 133 consecutive patients with groin lymph node metastases underwent superficial and deep dissection at the National Cancer Institute, Naples. Lymph node involvement was clinically evident in 84 patients and detected by sentinel node biopsy in 49 cases. The 5-year disease-free survival was significantly better for patients with superficial lymph node metastases than for patients with involvement of both superficial and deep lymph nodes (34.9% vs. 19.0%; P = 0.001). The 5-year melanoma-specific survival was also significantly better for patients with superficial node metastases only (55.6% vs. 33.3%; P = 0.001). Metastasis in the deep nodes is the strongest predictor of both disease-free and melanoma-specific survival. Deep groin dissection should be considered for all patients with groin clinical nodal involvement, but might be spared in patients with a positive sentinel node. Prospective studies will clarify the issue further.

Reconstruction/Repair of Iatrogenic Biliary Injuries: Is the Robot Offering a New Option? Short Clinical Report.

PubMed

Giulianotti, Pier Cristoforo; Quadri, Pablo; Durgam, Samarth; Bianco, Francesco Maria

2018-01-01

The aim of this study is to analyze perioperative outcomes of robotic reconstruction of iatrogenic biliary injuries and describe the surgical technique in detail. Iatrogenic bile duct injuries (BDIs) continue to be a major concern in open and laparoscopic cholecystectomy. In the past decade, robotic surgery has been applied to many different procedures showing technical advantages, especially in microsurgical fields. Few cases of robotic BDI reconstructions have been described in the literature so far. This is the first clinical series of consecutive patients undergoing robotic BDI reconstructions. This study is a single-surgeon retrospective review of a prospectively maintained database including 14 patients who underwent robot-assisted biliary reconstruction due to iatrogenic BDIs. In all, 14 patients underwent robot-assisted BDI reconstructions. The mean operative time, blood loss, and length of hospitalization were 280.6 min (SD = 132.0), 135.0 mL (SD = 169.7), and 8.4 days (SD = 6.7), respectively. The conversion rate to open surgery was 0%. Long-term follow-up was available in 85.7% (12 out of 14 patients) with a mean follow-up of 36.1 months (SD = 28.1). The >30-day complication rate was 14.3% (n = 2). These 2 patients presented with recurrent episodes of cholangitis due to hepatico-jejunostomy mild stenosis, which were successfully treated with transhepatic percutaneous biliary drainage and multiple dilatations. Robot-assisted BDI reconstruction is feasible, safe, and may represent an interesting option in expert hands. It maintains all the benefits of minimally invasive surgery and seems to have technical advantages in fine dissection and microsuturing in the liver hilum (magnified microsuturing). In this series, 14 patients with major BDIs were repaired with the robotic approach, with conversion and reoperation rates of 0%. Long-term outcome evaluation requires a longer follow up and larger series, but the initial results are promising.

Total robotic pancreaticoduodenectomy: a systematic review of the literature.

PubMed

Kornaropoulos, Michail; Moris, Demetrios; Beal, Eliza W; Makris, Marinos C; Mitrousias, Apostolos; Petrou, Athanasios; Felekouras, Evangelos; Michalinos, Adamantios; Vailas, Michail; Schizas, Dimitrios; Papalampros, Alexandros

2017-11-01

Pancreaticoduodenectomy (PD) is a complex operation with high perioperative morbidity and mortality, even in the highest volume centers. Since the development of the robotic platform, the number of reports on robotic-assisted pancreatic surgery has been on the rise. This article reviews the current state of completely robotic PD. A systematic literature search was performed including studies published between January 2000 and July 2016 reporting PDs in which all procedural steps (dissection, resection and reconstruction) were performed robotically. Thirteen studies met the inclusion criteria, including a total of 738 patients. Data regarding perioperative outcomes such as operative time, blood loss, mortality, morbidity, conversion and oncologic outcomes were analyzed. No major differences were observed in mortality, morbidity and oncologic parameters, between robotic and non-robotic approaches. However, operative time was longer in robotic PD, whereas the estimated blood loss was lower. The conversion rate to laparotomy was 6.5-7.8%. Robotic PD is feasible and safe in high-volume institutions, where surgeons are experienced and medical staff are appropriately trained. Randomized controlled trials are required to further investigate outcomes of robotic PD. Additionally, cost analysis and data on long-term oncologic outcomes are needed to evaluate cost-effectiveness of the robotic approach in comparison with the open technique.

Robotic surgery for colorectal cancer: systematic review of the literature.

PubMed

Papanikolaou, Ioannis G

2014-12-01

Surgical practice has been changed since the introduction of robotic techniques and robotic colorectal surgery is an emerging field. Innovative robotic technologies have helped surgeons overcome many technical difficulties of conventional laparoscopic surgery. Herein, we review the clinical studies regarding the application of surgical robots in resections for colorectal cancer. A systematic review of the literature was conducted for articles published up to September 9, 2012, using the MEDLINE database. The keywords that were used in various combinations were: "surgical robotics," "robotic surgery," "computer-assisted surgery," "colectomy," "sigmoid resection," "sigmoidectomy," and "rectal resection." Fifty-nine articles reporting on robot-assisted resections of colon and/or rectum were identified and 41 studies were finally included in the analysis. A total of 1635 colorectal procedures were performed: 254 right colectomies, 185 left colectomies/sigmoid resections, 969 anterior resections, 182 abdominoperineal or intersphincteric resections, 34 colectomies (without being specified as right or left), and 11 total/subtotal colectomies. In general, blood loss, conversion rates, and complications were low but the operative time was longer than the open procedures, whereas the duration of hospitalization was shorter. The number of harvested lymph nodes was also quite satisfactory. Robotic colorectal operations provide favorable results, with acceptable operative times and low conversion rates and morbidity. Surgical robots may provide additional benefits treating challenging pathologies, such as rectal cancer. Further clinical studies and long-term follow-up are required to better evaluate the outcomes of robotic colorectal surgery.

The University of Pennsylvania curriculum for training otorhinolaryngology residents in transoral robotic surgery.

PubMed

Sperry, Steven M; O'Malley, Bert W; Weinstein, Gregory S

2014-01-01

To define a curriculum for the development of robotic surgical skills in otorhinolaryngology residency training. A systematic review of the current literature on robotic surgery training was performed. Based on prior reports in other specialties, a curriculum for otorhinolaryngology residents was created that progresses through several modules, including didactics, inanimate skills laboratory, and operative experience. The curriculum for residents in otorhinolaryngology was designed as follows: didactics include an overview of the robotic device and instruments, a tutorial in basic controls and function, and a room setup and positioning. The anatomy and steps of transoral procedures are taught through books, videos, operative observations, and cadaver dissections. Skills are developed with a virtual reality robotic simulator and robotics labs. The operative experience progresses from case observation to bedside assistant to console surgeon. The role of the console surgeon progresses in a stepwise fashion, and the procedures of radical tonsillectomy, supraglottic partial laryngectomy, and base of tongue resection have been organized as a series of steps. A structured curriculum for training residents in transoral robotic surgery was developed. This training is important for otorhinolaryngology residents to acquire the knowledge and skills to perform robotic surgery safely. © 2015 S. Karger AG, Basel.

Management of well-differentiated thyroid cancer in 2010: perspectives of a head and neck surgical oncologist.

PubMed

Urken, Mark L

2010-01-01

To review the terminology and controversy regarding the performance of prophylactic lymph node dissection for patients without evidence suggestive of pathologic adenopathy. Terminology of lymph node levels in the neck and chest, and the issues regarding lymph node dissection, are reviewed. In addition, differences between lymph nodes are reviewed and discussed. Management of lymph nodes in this disease process has become the most contentious aspect of surgical decision-making due to the ambiguity of their prognostic significance and the prevalence of nodal metastases in very early primary tumors. Performance of prophylactic central compartment node dissection is not technically any more difficult than therapeutic node dissection when clinically significant nodes are encountered. It is therefore reasonable to consider this technique as an important adjunct to a total thyroidectomy for the purpose of enhanced disease staging, prevention of nodal recurrence, and avoidance of having to re-enter the previously operated central compartment. A recent study is reviewed and discussed in detail. The literature regarding the prognostic significance of extracapsular spread in lymph nodes is also presented. Morphologic characteristics of metastatic lymph nodes in thyroid cancer vary greatly. However, the reporting of these differences is lacking. The presence of extracapsular extension in a lymph node has prognostic significance. The clinician should be aware of these variations and the impact that they may have on recurrence risk and disease-specific survival.

Multi Robot Path Planning for Budgeted Active Perception with Self-Organising Maps

DTIC Science & Technology

2016-10-04

Multi- Robot Path Planning for Budgeted Active Perception with Self-Organising Maps Graeme Best1, Jan Faigl2 and Robert Fitch1 Abstract— We propose a...optimise paths for a multi- robot team that aims to maximally observe a set of nodes in the environment. The selected nodes are observed by visiting...regions, each node has an observation reward, and the robots are constrained by travel budgets. The SOM algorithm jointly selects and allocates nodes

Transitioning from video-assisted thoracic surgical lobectomy to robotics for lung cancer: are there outcomes advantages?

PubMed

Lee, Benjamin E; Korst, Robert J; Kletsman, Elaine; Rutledge, John R

2014-02-01

To determine if there are advantages to transitioning to robotics by a surgeon who is already proficient in performing video-assisted thoracic surgical (VATS) lobectomy. A single surgeon proficient in VATS lobectomy initiated a robotic lobectomy program, and a retrospective review was conducted of his patients undergoing minimally invasive lobectomy (robotics or VATS) for lung cancer between 2011 and 2012. Data collected included patient/tumor characteristics, morbidity, mortality, operative times, and length of hospital stay. Over a 24-month period, a total of 69 patients underwent minimally invasive lobectomy (35 robotic, 34 VATS). Patients in each group were similar in age and clinical stage. Robotic upper lobectomy operative times were longer than VATS (172 vs 134 minutes; P = .001), with no significant difference in lower lobectomies noted (140 vs 123 minutes; P = .1). Median length of stay was 3 days in both groups, and the median number of lymph nodes harvested was 18 (robotic) versus 16 (VATS; P = .42). Morbidity and mortality for robotic versus VATS were 11% versus 18% (P = .46) and 0% versus 3% (P = .49), respectively. There does not seem to be a significant advantage for an established VATS lobectomy surgeon to transition to robotics based on clinical outcomes. The learning curve for robotic upper lobectomies seems to be more significant than that for lower lobectomies. Copyright © 2014 The American Association for Thoracic Surgery. Published by Mosby, Inc. All rights reserved.

Randomized clinical trial of robot-assisted versus standard laparoscopic right colectomy.

PubMed

Park, J S; Choi, G-S; Park, S Y; Kim, H J; Ryuk, J P

2012-09-01

Robotic surgery was invented to overcome the demerits of laparoscopic technique. However, it is unclear whether robot-assisted colectomy (RAC) has significant clinical advantages over laparoscopically assisted colectomy (LAC) in treating colonic cancer. The aim of this study was to compare the surgical outcomes of RAC versus LAC for right-sided colonic cancer. Patients with right-sided colonic cancer were randomized to receive RAC or LAC. The primary outcome measure was length of hospital stay. Secondary outcomes were duration of operation, morbidity, postoperative pain, hospital costs and pathological quality of the specimen. Of 71 patients randomized, 70 (35 in each group) were included in the analysis. Hospital stay, surgical complications, postoperative pain score, resection margin clearance and number of lymph nodes harvested were similar in both groups. The duration of surgery was longer in the RAC group (195 versus 130 min; P < 0·001). No conversion to open surgery was needed in either group. Overall hospital costs were significantly higher for RAC (US $ 12,235 versus $ 10,320; P = 0·013); the higher costs were attributed primarily to the costs of surgery, including consumables. Robotic-assisted laparoscopic right colectomy was feasible but provided no benefit to justify the greater cost. NCT01042743 (http://www.clinicaltrials.gov). Copyright © 2012 British Journal of Surgery Society Ltd. Published by John Wiley & Sons, Ltd.

Low rates of loco-regional recurrence following extended lymph node dissection for gastric cancer.

PubMed

Muratore, A; Zimmitti, G; Lo Tesoriere, R; Mellano, A; Massucco, P; Capussotti, L

2009-06-01

The study by MacDonald et al. [Chemoradiotherapy after surgery compared with surgery alone for adenocarcinoma of the stomach or gastroesophageal junction. N Engl J Med 2001;345:725-30] has reported low loco-regional recurrence rates (19%) after gastric cancer resection and adjuvant radiotherapy. However, the lymph node dissection was often "inadequate". The aim of this retrospective study is to analyse if an extended lymph node dissection (D2) without adjuvant radiotherapy may achieve comparable loco-regional recurrence rates. A prospective database of 200 patients who underwent a curative resection for gastric carcinoma from January 2000 to December 2006 was analysed. D2 lymph node dissection was standard. Recurrences were categorized as loco-regional, peritoneal, or distant. No patients received neoadjuvant or adjuvant radiotherapy. The in-hospital mortality rate was 1% (2 patients). The mean number of dissected lymph nodes was 25.9. Overall and disease-free survival at 5years were 60.7% and 61.2% respectively. During the follow-up, 60 patients (30%) have recurred at 76 sites: 38 (50%) distant metastases, 25 (32.9%) peritoneal metastases, and 13 (17.1%) loco-regional recurrences. The loco-regional recurrence was isolated in 6 patients and associated with peritoneal or distant metastases in 7 patients. The mean time to the first recurrence was 18.9 (95% confidence interval: 15.0-21.9) months. Extended lymph node dissection is safe and warrants low loco-regional recurrence rates.

Transoral robotic thyroid surgery

PubMed Central

Clark, James H.; Kim, Hoon Yub

2015-01-01

There is currently significant demand for minimally invasive thyroid surgery; however the majority of proposed surgical approaches necessitate a compromise between minimal tissue dissection with a visible cervical scar or extensive tissue dissection with a remote, hidden scar. The development of transoral endoscopic thyroid surgery however provides an approach which is truly minimally invasive, as it conceals the incision within the oral cavity without significantly increasing the amount of required dissection. The transoral endoscopic approach however presents multiple technical challenges, which could be overcome with the incorporation of a robotic operating system. This manuscript summarizes the literature on the feasibility and current clinical experience with transoral robotic thyroid surgery. PMID:26425456

Forces exerted during microneurosurgery: a cadaver study

PubMed Central

Marcus, Hani J; Zareinia, Kourosh; Gan, Liu Shi; Yang, Fang Wei; Lama, Sanju; Yang, Guang-Zhong; Sutherland, Garnette R

2014-01-01

Background A prerequisite for the successful design and use of robots in neurosurgery is knowledge of the forces exerted by surgeons during neurosurgical procedures. The aim of the present cadaver study was to measure the surgical instrument forces exerted during microneurosurgery. Methods An experimental apparatus was set up consisting of a platform for human cadaver brains, a Leica microscope to provide illumination and magnification, and a Quanser 6 Degrees-Of-Freedom Telepresence System for tissue manipulation and force measurements. Results The measured forces varied significantly depending on the region of the brain (P = 0.016) and the maneuver performed (P < 0.0001). Moreover, blunt arachnoid dissection was associated with greater force exertion than sharp dissection (0.22 N vs. 0.03 N; P = 0.001). Conclusions The forces necessary to manipulate brain tissue were surprisingly low and varied depending on the anatomical structure being manipulated, and the maneuver performed. Knowledge of such forces could well increase the safety of microsurgery. © 2014 The Authors. The International Journal of Medical Robotics and Computer Assisted Surgery published by John Wiley & Sons, Ltd. PMID:24431265

Direct target NOTES: prospective applications for next generation robotic platforms.

PubMed

Atallah, S; Hodges, A; Larach, S W

2018-05-01

A new era in surgical robotics has centered on alternative access to anatomic targets and next generation designs include flexible, single-port systems which follow circuitous rather than straight pathways. Such systems maintain a small footprint and could be utilized for specialized operations based on direct organ target natural orifice transluminal endoscopic surgery (NOTES), of which transanal total mesorectal excision (taTME) is an important derivative. During two sessions, four direct target NOTES operations were conducted on a cadaveric model using a flexible robotic system to demonstrate proof-of-concept of the application of a next generation robotic system to specific types of NOTES operations, all of which required removal of a direct target organ through natural orifice access. These four operations were (a) robotic taTME, (b) robotic transvaginal hysterectomy in conjunction with (c) robotic transvaginal salpingo-oophorectomy, and in an ex vivo model, (d) trans-cecal appendectomy. Feasibility was demonstrated in all cases using the Flex ® Robotic System with Colorectal Drive. During taTME, the platform excursion was 17 cm along a non-linear path; operative time was 57 min for the transanal portion of the dissection. Robotic transvaginal hysterectomy was successfully completed in 78 min with transvaginal extraction of the uterus, although laparoscopic assistance was required. Robotic transvaginal unilateral salpingo-oophorectomy with transvaginal extraction of the ovary and fallopian tube was performed without laparoscopic assistance in 13.5 min. In an ex vivo model, a robotic trans-cecal appendectomy was also successfully performed for the purpose of demonstrating proof-of-concept only; this was completed in 24 min. A flexible robotic system has the potential to access anatomy along circuitous paths, making it a suitable platform for direct target NOTES. The conceptual operations posed could be considered suitable for next generation robotics once the technology is optimized, and after further preclinical validation.

[Implementation of a robotic video-assisted thoracic surgical program].

PubMed

Baste, J-M; Riviera, C; Nouhaud, F-X; Rinieri, P; Melki, J; Peillon, C

2016-03-01

Recent publications from North America have shown the benefits of robot-assisted thoracic surgery. We report here the process of setting up such a program in a French university centre and early results in a unit with an average treatment volume. Retrospective review of a single institution database. The program was launched after a 6-month preparation period. From January 2012 to January 2013, totally endoscopic, full robot-assisted procedures were performed on 30 patients (17 males). Median age was 54 [Q1-Q3, 48-63] years and ASA score 2 [1,2]. Operative procedures included thymectomy (9 ; 30%), lobectomy with nodes resection (11 ; 38%), segmentectomy (4 ; 14%), lymphadenectomy (3 ; 10%), Bronchogenic cyst (2, 5%) and posterior mediastinal mass resection (1 ; 3%). No conversion was required. Median blood loss was 50mL [10-100]. Median operating time was 135 min (105-165) including 30 min [20-40] for docking, 90min for robot-assisted operating [70-120] and 15 min [10-15] for lesion extraction. CO2 insufflation was used in 28 cases (93%). Hospital stay was 4 days [4-6] with 6 minor complications (20%) (Grade 1 according to the Clavien-Dindo classification). After a median 4 months follow-up [2-7], all patients were alive and demonstrated a good quality of life. This series suggests that full robotic thoracic procedures are safe and effective treatment for various pathologies, with low morbidity and without a significant learning curve, even in a lower volume centre. This technology should accompany the development of minimally invasive thoracic surgery. The importance of robotic training should be emphasized to optimize procedures and costs. Copyright © 2015 SPLF. Published by Elsevier Masson SAS. All rights reserved.

Development and Assessment of a Transoral Robotic Surgery Curriculum to Train Otolaryngology Residents.

PubMed

White, Joseph; Sharma, Arun

2018-05-30

(1) To develop a multifaceted didactic and hands-on curriculum to prepare otolaryngology residents to perform transoral robotic surgery (TORS) and safely transition to the operating room. (2) To assess the effectiveness of the TORS curriculum. Learning objectives were developed and a curriculum was formulated utilizing five unique modalities: focused didactic reading, online training modules, backpack console simulations, videos of TORS cases, and hands-on cadaveric dissections with the robotic surgical system in a simulated operating room. The trainees completed a nine-item self-assessment of their skill level using a Likert scale. Five senior otolaryngology residents completed the TORS curriculum. Before and after the cadaveric dissections, there was improvement in each of the nine items assessed. Composite scores were calculated and there was significant improvement from predissection (15.2 ± 2.2) to postdissection (31.4 ± 1.9) (p = 0.002). The current study demonstrates the feasibility of implementing a multifaceted TORS curriculum which incorporates robotic cadaveric dissection for otolaryngology residents. Residents demonstrate marked improvement in skills with the TORS curriculum. A TORS curriculum which includes robotic cadaveric dissection can improve surgical skills and serve as a key component of residency TORS education. © 2018 S. Karger AG, Basel.

Robotic surgery of locally advanced gastric cancer: a single-surgeon experience of 41 cases.

PubMed

Vasilescu, C; Procopiuc, L

2012-01-01

The mainstay of curative gastric cancer treatment is open gastric resection with regional lymph node dissection. Minimally invasive surgery is yet to become an established technique with a well defined role. Robotic surgery has by-passed some of the limitations of conventional laparoscopy and has proven both safe and feasible. We present our initial experience with robotic surgery based on 41 gastric cancer patients. We especially wish to underline the advantages of the robotic system when performing the digestive tract anastomoses. We present the techniques of end-to-side eso-jejunoanastomoses (using a circular stapler or manual suture) and side-to-side eso-jejunoanastomoses. In our hands, the results with circular stapled anastomoses were good and we advocate against manual suturing when performing anastomoses in robotic surgery. Moreover, we recommend performing totally intracorporeal anastomoses which have a better post-operative outcome, especially in obese patients. We present three methods of realising the total intracorporeal eso-jejuno-anastomosis with a circular stapler: manual purse-string suture, using the OrVil and the double stapling technique. The eso-jejunoanastomosis is one of the most difficult steps in performing the total gastrectomy, but these techniques allow the surgeon to choose the best option for each case. We consider that surgeons who undertake total gastrectomies must have a special training in performing these anastomoses.

A Prospective Study of Level IIB Nodal Metastasis (Supraretrospinal) in Clinically N0 Oral Squamous Cell Carcinoma in Indian Population.

PubMed

Chheda, Yogen P; Pillai, Sundaram K; Parikh, Devendra G; Dipayan, Nandy; Shah, Shakuntala V; Alaknanda, Gupta

2017-06-01

Oral cavity carcinoma is the most common cancer in Indian population. Metastatic nodal disease is the most important prognostic factor for oral cancers. In head and neck cancers with clinically N0 neck, standard selective neck dissection is performed by protecting the spinal accessory nerve to remove level IIA & IIB lymph nodes. The purpose of this study was to analyze the significance of level IIB dissection in patients of oral cavity cancer who underwent primary surgery with functional neck dissection. Two hundred ten patients with clinically N0 neck underwent neck dissection, where level IIB lymph nodes were dissected, labelled and processed separately. Among 210 patients of clinically N0 neck, 168 patients were pathologically N0 (80 %). Out of remaining 42 (20 %), 36 (17.14 %) were pN1 and 6 (2.86 %) were pN2. Among those with pN1 (36), level IB was involved in 24 patients (66.67 %) and level IIA was involved in 12 patients (33.33 %). Only 2 patients had involvement of level IIB lymph nodes. Among 6 patients of pN2 disease, 4 patients had simultaneous involvement of level IB and level IIA lymph nodes. Remaining 2 patients had isolated involvement of level III lymph nodes. Thus only 2 patients (< 1 %) out of 210 clinically N0 oral squamous cell carcinoma showed level IIB lymph node involvement. Thus we conclude that a frozen section of level 2a is advisable to decide the need for level 2b node dissection in clinically N0 neck as the sensitivity of clinical evaluation is extremely low.

Sentinel lymph node biopsy under fluorescent indocyanin green guidance: Initial experience.

PubMed

Aydoğan, Fatih; Arıkan, Akif Enes; Aytaç, Erman; Velidedeoğlu, Mehmet; Yılmaz, Mehmet Halit; Sager, Muhammet Sait; Çelik, Varol; Uras, Cihan

2016-01-01

Sentinel lymph node biopsy can be applied by using either blue dye or radionuclide method or both in breast cancer. Fluorescent imaging with indocyanine green is a new defined method. This study evaluates the applicability of sentinel lymph node biopsy via fluorescent indocyanine green. IC-VIEW (Pulsion Medical Systems AG, Munich, Germany) infrared visualization system was used for imaging. Two mL of indocyanine green was injected to visualize sentinel lymph nodes. After injection, subcutaneous lymphatics were traced and sentinel lymph nodes were found with simultaneous imaging. Sentinel lymph nodes were excised under fluorescent light guidance, and excised lymph nodes were examined histopathologically. Patients with sentinel lymph node metastases underwent axillary dissection. Four patients with sentinel lymph node biopsy due to breast cancer were included in the study. Sentinel lymph nodes were visualized with indocyanine green in all patients. The median number of excised sentinel lymph node was 2 (2-3). Two patients with lymph node metastasis underwent axillary dissection. No metastasis was detected in lymph nodes other than the sentinel nodes in patients with axillary dissection. There was no complication during and after the operation related to the method. According to our limited experience, sentinel lymph node biopsy under fluorescent indocyanine green guidance, which has an advantage of simultaneous visualization, is technically feasible.

Laparoscopic surgery for endometrial cancer: increasing body mass index does not impact postoperative complications.

PubMed

Helm, C William; Arumugam, Cibi; Gordinier, Mary E; Metzinger, Daniel S; Pan, Jianmin; Rai, Shesh N

2011-09-01

To determine the effect of body mass index on postoperative complications and the performance of lymph node dissection in women undergoing laparoscopy or laparotomy for endometrial cancer. Retrospective chart review of all patients undergoing surgery for endometrial cancer between 8/2004 and 12/2008. Complications graded and analyzed using Common Toxicity Criteria for Adverse Events ver. 4.03 classification. 168 women underwent surgery: laparoscopy n=65, laparotomy n=103. Overall median body mass index 36.2 (range, 18.1 to 72.7) with similar distributions for age, body mass index and performance of lymph node dissection between groups. Following laparoscopy vs. laparotomy the percent rate of overall complications 53.8:73.8 (p=0.01), grade ≥3 complications 9.2:34.0 (p<0.01), ≥3 wound complications 3.1:22.3 (p<0.01) and ≥3 wound infection 3.1:20.4 (p=0.01) were significantly lower after laparoscopy. In a logistic model there was no effect of body mass index (≥36 and<36) on complications after laparoscopy in contrast to laparotomy. Para-aortic lymph node dissection was performed by laparoscopy 19/65 (29%): by laparotomy 34/103 (33%) p=0.61 and pelvic lymph node dissection by laparoscopy 21/65 (32.3%): by laparotomy 46/103 (44.7%) p=0.11. Logistic regression analysis revealed that for patients undergoing laparoscopy for stage I disease there was an inverse relationship between the performance of both para-aortic lymph node dissection and pelvic lymph node dissection and increasing body mass index (p=0.03 and p<0.01 respectively) in contrast to the laparotomy group where there was a trend only (p=0.09 and 0.05). For patients undergoing laparoscopy, increasing body mass index did not impact postoperative complications but did influence the decision to perform lymph node dissection.

Tracheobronchial lesions following esophagectomy: erosions, ulcers, and fistulae, and the predictive value of lymph node-related factors.

PubMed

Maruyama, Kiyotomi; Motoyama, Satoru; Sato, Yusuke; Hayashi, Kaori; Usami, Shuetu; Minamiya, Yoshihiro; Ogawa, Jun-ichi

2009-04-01

Following esophagectomy, tracheobronchial lesions (TBLs) can occur as a result of ischemia caused by extensive dissection around the tracheobronchus. In this study we assessed the causes and clinical features of these complications, paying particular attention to lymph node (LN)-related factors. Between January 2000 and March 2007, 305 consecutive patients underwent subtotal esophagectomy using a transthoracic approach with LN dissection for thoracic esophageal cancer. TBLs, including erosions, ulcers, and fistulae, without traumatic injury during the operation, were detected during bronchoscopic examinations performed twice daily after the operation. The correlation between TBLs and tumor or surgical factors were analyzed. TBLs were observed in 14 patients, accounting for an overall incidence of 5%; these included 6 fistulae, 5 ulcers, and 3 erosions. Cases with TBLs significantly more often involved three-field LN dissections (3FLD) than those without TBLs. Six (43%) patients with TBLs had more than four metastatic lymph nodes, while 9 (64%) had cervical and upper-mediastinal LN metastasis (p=0.034 and 0.041, respectively). More than 60 LNs were dissected from 10 (71%) patients with TBLs (p=0.021), and logistic regression analysis revealed that dissection of more than 60 lymph nodes and 3FLD were independent predictors of TBLs. Esophageal cancer patients requiring extensive LN dissection of more than 60 nodes and/or 3FLD have an increased risk of developing a TBL during their postoperative course.

Extraperitoneal lymph node dissection in locally advanced cervical cancer; the prognostic factors associated with survival

PubMed Central

Köse, Mehmet Faruk; Kiseli, Mine; Kimyon, Günsu; Öcalan, Reyhan; Yenen, Müfit Cemal; Tulunay, Gökhan; Turan, Ahmet Taner; Üreyen, Işın; Boran, Nurettin

2017-01-01

Objective: Surgical staging was recently recommended for the decision of treatment in locally advanced cervical cancer. We aimed to investigate clinical outcomes as well as factors associated with overall survival (OS) in patients with locally advanced cervical cancer who had undergone extraperitoneal lymph node dissection and were managed according to their lymph node status. Material and Methods: The medical records of 233 women with stage IIb-IVa cervical cancer who were clinically staged and underwent extraperitoneal lymph node dissection were retrospectively reviewed. Paraaortic lymph node status determined the appropriate radiotherapeutic treatment field. Surgery-related complications and clinical outcomes were evaluated. Results: The median age of the patients was 52 years (range, 26-88 years) and the median follow-up time was 28.4 months (range, 3-141 months). Thirty-one patients had laparoscopic extraperitoneal lymph node dissection and 202 patients underwent laparotomy. The number of paraaortic lymph nodes extracted was similar for both techniques. Sixty-two (27%) of the 233 patients had paraaortic lymph node metastases. The 3-year and 5-year OS rates were 55.1% and 46.5%, respectively. The stage of disease, number of metastatic paraaortic lymph nodes, tumor type, and paraaortic lymph node status were associated with OS. In multivariate Cox regression analyses, tumor type, stage, and presence of paraaortic lymph node metastases were the independent prognostic factors of OS. Conclusion: Paraaortic lymph node metastasis is the most important prognostic factor affecting survival. Surgery would give hints about the prognosis and treatment planning of the patient. PMID:28400350

Laparoscopic pancreatoduodenectomy with superior mesenteric artery-first approach and pancreatogastrostomy assisted by mini-laparotomy.

PubMed

Zimmitti, Giuseppe; Manzoni, Alberto; Addeo, Pietro; Garatti, Marco; Zaniboni, Alberto; Bachellier, Philippe; Rosso, Edoardo

2016-04-01

Laparoscopic pancreatoduodenectomy (LPD) is a complex procedure. Critical steps are achieving a negative retroperitoneal margin and re-establishing pancreatoenteric continuity minimizing postoperative pancreatic leak risk. Aiming at increasing the rate of R0 resection during pancreatoduodenectomy, many experienced teams have recommended the superior mesenteric artery (SMA)-first approach, consisting in early identification of the SMA at its origin, with further resection guided by SMA anatomic course. We describe our technique of LPD with SMA-first approach and pancreatogastrostomy assisted by mini-laparotomy. The video concerns a 77-year-old man undergoing our variant of LPD for a 2.5-cm pancreatic head mass. After kocherization, the SMA is identified above the left renocaval confluence and dissected-free from the surrounding tissue. Dissection of the posterior pancreatic aspect exposes the confluence between splenic vein, superior mesenteric vein (SMV), and portal vein. Following duodenal section, the common hepatic artery is dissected and the gastroduodenal artery sectioned at the origin. The first jejunal loop is divided, skeletonized, and passed behind the superior mesenteric vessel. Following pancreatic transection, the uncinate process is dissected from the SMV and the SMA is cleared from retroportal tissue rejoining the previously dissected plain. Laparoscopic choledocojejunostomy is followed by a mini-laparotomy-assisted pancreatogastrostomy, performed as previously described, and a terminolateral gastrojejeunostomy. Twelve patients underwent our variant of LPD (July 2013-May 2015). Female/male ratio was 3:1, median age 65 years (range 57-79), median operation duration 590 min (580-690), intraoperative blood loss 150 cl (100-250). R0 resection rate was 100 %, and the median number of resected lymph nodes was 24 (22-28). Postoperative complications were grade II in two patients and IIIa in one. Median postoperative length of stay was 16 days (14-21). LPD with SMA-first approach with pancreatogastrostomy assisted by a mini-laparotomy well combines the benefits of laparoscopy with low risk of postoperative complications and high rate of curative resection.

RoCoMAR: robots' controllable mobility aided routing and relay architecture for mobile sensor networks.

PubMed

Le, Duc Van; Oh, Hoon; Yoon, Seokhoon

2013-07-05

In a practical deployment, mobile sensor network (MSN) suffers from a low performance due to high node mobility, time-varying wireless channel properties, and obstacles between communicating nodes. In order to tackle the problem of low network performance and provide a desired end-to-end data transfer quality, in this paper we propose a novel ad hoc routing and relaying architecture, namely RoCoMAR (Robots' Controllable Mobility Aided Routing) that uses robotic nodes' controllable mobility. RoCoMAR repeatedly performs link reinforcement process with the objective of maximizing the network throughput, in which the link with the lowest quality on the path is identified and replaced with high quality links by placing a robotic node as a relay at an optimal position. The robotic node resigns as a relay if the objective is achieved or no more gain can be obtained with a new relay. Once placed as a relay, the robotic node performs adaptive link maintenance by adjusting its position according to the movements of regular nodes. The simulation results show that RoCoMAR outperforms existing ad hoc routing protocols for MSN in terms of network throughput and end-to-end delay.

RoCoMAR: Robots' Controllable Mobility Aided Routing and Relay Architecture for Mobile Sensor Networks

PubMed Central

Van Le, Duc; Oh, Hoon; Yoon, Seokhoon

2013-01-01

In a practical deployment, mobile sensor network (MSN) suffers from a low performance due to high node mobility, time-varying wireless channel properties, and obstacles between communicating nodes. In order to tackle the problem of low network performance and provide a desired end-to-end data transfer quality, in this paper we propose a novel ad hoc routing and relaying architecture, namely RoCoMAR (Robots' Controllable Mobility Aided Routing) that uses robotic nodes' controllable mobility. RoCoMAR repeatedly performs link reinforcement process with the objective of maximizing the network throughput, in which the link with the lowest quality on the path is identified and replaced with high quality links by placing a robotic node as a relay at an optimal position. The robotic node resigns as a relay if the objective is achieved or no more gain can be obtained with a new relay. Once placed as a relay, the robotic node performs adaptive link maintenance by adjusting its position according to the movements of regular nodes. The simulation results show that RoCoMAR outperforms existing ad hoc routing protocols for MSN in terms of network throughput and end-to-end delay. PMID:23881134

Rationale of lymph node dissection for breast cancer--from the viewpoint of analysis of axillary lymphatic flow using activated carbon particle CH40.

PubMed

Sawai, K; Hagiwara, A; Shimotsuma, M; Sakakibara, T; Imanishi, T; Takemoto, Y; Takahashi, T

1996-03-01

In order to rationalize lymph node dissection for breast cancer, we reviewed regional lymphatic flow from the mesial and outer half of the breast using intra-tumoral injection of activated carbon particles (CH40). Seventy patients with breast cancer were included in this study. Cancers were located in the mesial half of the breast in 25 cases and in its outer half in 41 cases. Since regional lymph nodes were blackened by CH40, lymph node dissection was performed easily and small lymph nodes could be readily examined. The average number of resected nodes in each case was 29.4. When CH40 was injected into the mesial half of the breast, the rates of blackened nodes (number of macroscopically blackened lymph nodes/number of total removed lymph nodes) in the stations were 46.6% (No. 1a), 41.4% (No. 1b), 62.1% (No. 1c), 61.8% (No. 2), 69.2.% (No. 2h), and 65.6% (No. 3). When CH40 was injected into outer half of the breast, those were 62.0% (No. 1a), 64.3% (No. 1b), 68.7% (No. 1c), 75.3% (No. 2), and 67.8% (No. 2h). Regardless of tumor location, the rates of blackened nodes were high in each station. In conclusion, regardless of tumor location it is impossible to determine the level of axillary dissection for breast cancer. It should be all or nothing.

[The role of elective neck dissection during salvage laryngectomy - a retrospective analysis].

PubMed

Hussain, Timon; Kanaan, Oliver; Höing, Benedikt; Dominas, Nina; Lang, Stephan; Mattheis, Stefan

2018-05-16

Elective neck dissection of the N0-neck is routinely performed during salvage laryngectomy (SLE) for recurrent cancer of the larynx or hypopharynx. The therapeutic benefit of additional neck dissection must be weighed against the risk of increased morbidity. In this retrospective analysis, we assessed oncologic parameters of patients who underwent SLE with concurrent bilateral neck dissection for recurrent laryngeal or hypopharyngeal cancer. We compared these data with patients who underwent primary laryngectomy (LE) with bilateral neck dissection for laryngeal and hypopharyngeal cancer.19 patients who had undergone SLE and 83 patients after LE were included in the analysis. The majority of patients had advanced stage tumors prior to LE or primary radiation therapy, as well as advanced stage recurrent tumors prior to SLE. Prior to SLE, 5 % of all patients (n = 1) had clinically pathologic lymph nodes, compared to 47 % (n = 39) prior to LE. 17 % (n = 14) of patients with LE and bilateral neck dissection had occult lymph node metastases, compared to 5 % (n = 1) of patients who underwent SLE with bilateral neck dissection. Overall, 55 % (n = 44) of patients who underwent LE had positive cervical lymph nodes, compared to 10 % (n = 2) of SLE patients. Lymph node yield was higher in patients with LE than in SLE-patients (37.3 vs. 18.7, p < 0.001). 5-year OS was 50 % after LE and 33 % after SLE. Cervical lymph node metastases are rare in patients who undergo SLE for recurrent cancers of the larynx of hypopharynx. However, occult metastases do occur. Therefore, since SLE is the final curative therapy, additional neck dissection should be taken into consideration. © Georg Thieme Verlag KG Stuttgart · New York.

Incidental cervical metastases from thyroid carcinoma during neck dissection.

PubMed

Périé, S; Torti, F; Lefevre, M; Chabbert-Buffet, N; Jafari, A; Lacau St Guily, J

2016-12-01

To quantify and discuss the prevalence of unsuspected thyroid lymph node metastases discovered in specimens from neck dissection for head and neck squamous cell carcinoma (HNSCC) and discuss the impact on patient management. Retrospective study between May 2004 and January 2007. University hospital. Pathological analysis of cervical lymph node dissection performed during surgery for HNSCC in a total of 349 neck dissections in 266 consecutive patients. Twenty-one patients showed metastatic lymph nodes from thyroid cancer (prevalence 7.9%): 13 cases were metastatic from a papillary thyroid carcinoma and 8 cases from a follicular carcinoma. In 5 of the 21 patients, classical dissection was associated to recurrent nerve dissection and unilateral lobectomy; no thyroid carcinoma was found. Thirteen patients received radiotherapy for HNSCC. Follow-up comprised annual ultrasonographic examination of the neck and thyroid in these 21 patients. Total thyroidectomy was decided on in 5, with discovery of 3 micro-papillary thyroid carcinomas, in a single patient (complementary 131 I treatment). No thyroid carcinomas were found for the other 4 patients. No patients died from thyroid carcinoma during follow-up (mean: 41 months). The prevalence of lymph node metastasis from thyroid carcinoma in cervical lymph node dissection during treatment of HNSCC seems higher (7.9%) than rates reported in the literature (0.3 to 1.6%). This may be due to the histopathological methods employed. Management of patients should be discussed in the light of thyroid ultrasonography and prognosis of HNSCC. Copyright © 2016 Elsevier Masson SAS. All rights reserved.

Lymph node dissection for melanoma using tumescence local anaesthesia: an observational study.

PubMed

Kofler, Lukas; Breuninger, Helmut; Häfner, Hans-Martin; Schweinzer, Katrin; Schnabl, Saskia M; Eigentler, Thomas K; Leiter, Ulrike

2018-04-01

The possibility that tumescence local anaesthesia (TLA) may lead to dissemination of tumour cells in lymph nodes is presently unclear. To evaluate whether infiltration by TLA influences metastatic spread and survival probability, compared to general anaesthesia (GA), based on lymph node dissection in melanoma patients. In total, 281 patients (GA: 162; TLA: 119) with cutaneous melanoma and clinically or histologically-confirmed metastases in regional lymph nodes were included. All patients underwent complete lymph node dissection. Median follow-up was 70 months. The rate of lymph node recurrence at the dissection site was 25.3% in the GA group and 17.6% in the TLA group (p = 0.082). No significant difference was found concerning 10-year melanoma-specific survival (GA: 56.2%, TLA: 67.4%; p = 0.09), disease-free survival (GA: 72.8 %, TLA: 81.1%; p = 0.095), or lymph node-free survival (GA: 72.8%, TLA: 81.1%; p = 0.095). Distant metastases-free survival appeared to be slightly reduced in the TLA group (GA: 49.9%, TLA: 64.0%; p = 0.025). No differences were identified between the GA and TLA groups regarding prognostic outcome for overall survival or disease-free survival.

A Simple Dissection Method for the Conduction System of the Human Heart

ERIC Educational Resources Information Center

Yanagawa, Nariaki; Nakajima, Yuji

2009-01-01

A simple dissection guide for the conduction system of the human heart is shown. The atrioventricular (AV) node, AV bundle, and right bundle branch were identified in a formaldehyde-fixed human heart. The sinu-atrial (SA) node could not be found, but the region in which SA node was contained was identified using the SA nodal artery. Gross…

Transoral robotic supraglottic partial laryngectomy.

PubMed

Kayhan, Fatma Tülin; Kaya, Kamil Hakan; Altintas, Ahmet; Sayin, Ibrahim

2014-07-01

Transoral robotic supraglottic laryngectomy is a new surgical way to perform endolaryngeal resection of supraglottic laryngeal carcinoma. The aim of this report was to present our initial experience about transoral robotic supraglottic laryngectomy for early supraglottic cancer. Subjects with early squamous cell carcinoma (T1-T2) of supraglottic region who managed using transoral robotic surgery in a tertiary referral center were included in the study. The technique of robot-assisted resection, intraoperative blood loss, mean robotic operating time, pathologic margin status, postoperative extubation, need for a tracheotomy, and length of hospitalization, complications, duration of oral nutrition, and neck dissection and radiotherapy needs were evaluated. Thirteen subjects (12 men, 1 woman) with T1-T2 supraglottic carcinoma were successfully operated on with transoral robotic surgery. In all subjects, negative margins were obtained. The mean total robotic surgery time was 31.6 (SD, 16.2) minutes (range, 20-80 minutes). Mean total blood loss was less than 40 mL. Subjects started oral nutrition with a mean of 10.8 (SD, 8.9) days (range, 4-30 days) postoperatively. The mean hospitalization was 15.4 (SD, 10.4) days (range, 7-42 days). Transoral robotic supraglottic laryngectomy with the da Vinci robotic system can be regarded as a feasible, safe, and effective technique. Although short-term results seem discouraging, long-term results are needed to evaluate the oncologic safety.

[Analysis of the patterns of cervical lymph node recurrence in patients with cN0 papillary thyroid carcinoma after central neck lymph node dissection].

PubMed

Huang, Hui; Xu, Zhengang; Wang, Xiaolei; Wu, Yuehuang; Liu, Shaoyan

2015-10-01

To retrospectively analyze the long-term results of prophylactic central lymph node dissection in cN0 papillary thyroid carcinoma (PTC), and investigate the treatment method of the cervical lymph nodes for cN0 PTC. One hundred and thirty-six patients with cN0 PTC were treated by surgery at the Cancer Hospital of Chinese Academy of Medical Sciences from 2000 to 2006. Their clinicopathological characteristics, surgical procedures and survival outcomes were collected and analyzed. The occult lymph node metastasis rate in central compartment was 61.0%. The average number of positive lymph nodes was 2.47 (1-13), in which 54 patients had 1-2 and 29 patients had ≥ 3 positive lymph nodes. Multiple logistic regression analysis showed that age less than 45 (P=0.001, OR 3.571, 95% CI 1.681-7.587)and extracapsular spread (ECS) (P=0.015, OR 2.99, 95% CI 1.241-7.202)were independent risk factors for lymph node metastasis in the central compartment. The ten-year cumulative overall survival rate was 98.3% and cumulative lateral neck metastasis rate was 25.2%. Multivariate analysis with Cox regression model showed that ECS (P=0.001, OR 5.211, 95% CI1.884-14.411) and positive lymph nodes in the central compartment ≥ 3 (P=0.009, OR 4.005, 95% CI 1.419-11.307) were independent risk factors for lymph node recurrence in the lateral neck region. The distribution of recurrent lymph nodes: level IV (82.4%), level III (64.7%), level II (29.4%) and level V (11.8%). Routine central lymph node dissection, at least unilateral, should be conducted for cN0 papillary thyroid carcinoma. Attention should be paid to the treatment of lateral neck region in patients with cN0 papillary thyroid carcinoma. Selective neck dissection is suggested for cN0 PTC with ECS or positive central lymph nodes ≥ 3, or both. The range of dissection should include level III and IV at least.

Anatomical study of the left superior mediastinal lymphatics for tracheal branches of left recurrent laryngeal nerve-preserving mediastinoscope-assisted surgery in esophageal cancer.

PubMed

Nakajima, Yutaka; Tokairin, Yutaka; Nakajima, Yasuaki; Kawada, Kenro; Nagai, Kagami; Yamaguchi, Kumiko; Akita, Keiichi; Kawano, Tatsuyuki

2018-03-01

Curative treatment of esophageal cancer requires meticulous superior mediastinal lymphadenectomy, in addition to esophagectomy, because superior mediastinal lymph node metastases are common in esophageal cancer. When preserving the tracheal branches of the left recurrent laryngeal nerve (RLN), good anatomical understanding is required for confirmation of the positional relationships between the courses of lymphatic vessels, lymph node distribution, and the left RLN and its tracheal branches. We performed a detailed anatomical examination of these relationships. Macroscopic anatomical observation and histological examination was performed on cadavers. In addition to hematoxylin and eosin staining, immunostaining using antipodoplanin antibody D2-40 (podoplanin) was performed to identify the lymphatic vessels. The tracheal branches of the left RLN were clearly observed, but no lymphatic vessels crossing the ventral or dorsal side of the branches were identified either macro-anatomically or histologically. No complex lymphatic network structure straddling the plane composed of tracheal branches of the left RLN was found in the left superior mediastinum. This suggests that dissection of the lymph nodes around the left RLN via the pneumomediastinum method using the left cervical approach may allow preservation of the tracheal branches of the left RLN by maintaining dissection accuracy.

Clinical value and indication for the dissection of lymph nodes posterior to the right recurrent laryngeal nerve in papillary thyroid carcinoma.

PubMed

Luo, Ding-Cun; Xu, Xiao-Cheng; Ding, Jin-Wang; Zhang, Yu; Peng, You; Pan, Gang; Zhang, Wo

2017-10-03

Lymph nodes posterior to the right recurrent laryngeal nerve (LN-prRLN) are common sites of nodal recurrence after the resection of papillary thyroid carcinoma (PTC). However, the indication for LN-prRLN dissection remains debatable. We therefore studied the relationships between LN-prRLN metastasis and the clinicopathological characteristics in 306 patients with right or bilateral PTC who underwent LN-prRLN dissection. We found that LN-prRLN metastasis occurred in 16.67% of PTC and was associated with a number of the clinicopathological features. The receiver-operator characteristic (ROC) analysis showed that the areas under the ROC curves for the prediction of LN-prRLN metastasis by the risk factors age < 35.5 years, right tumor size > 0.85 cm, lymph node (right cervical central VI-1) number > 1.5, metastatic lymph node (right cervical central VI-1) size > 0.45 cm, and lymph node number in the right cervical lateral compartment > 0.5 were 0.601, 0.815, 0.813, 0.725, and 0.743, respectively. In conclusion, the risk factors for LN-prRLN metastasis in patients suffering right thyroid lobe or bilateral PTC include age ≤ 35.5 years, right tumor size ≥ 0.85 cm, capsular invasion, metastatic lymph node (right cervical central VI-1) number ≥ 2, metastatic lymph node (right cervical central VI-1) size ≥ 0.45 cm, and metastatic lymph node number in the right cervical lateral compartment ≥ 1. In patients whose risk factors can be identified pre-operatively or intraoperatively, the dissection of LN-pr-RLN should be considered during right cervical central compartment dissection.

First year experience of robotic-assisted laparoscopic surgery with 153 cases in a general surgery department: indications, technique and results.

PubMed

Tomulescu, V; Stănciulea, O; Bălescu, I; Vasile, S; Tudor, St; Gheorghe, C; Vasilescu, C; Popescu, I

2009-01-01

Robotic surgery was developed in response to the limitations and drawbacks of laparoscopic surgery. Since 1997 when the first robotic procedure was performed various papers pointed the advantages of robotic-assisted laparoscopic surgery, this technique is now a reality and it will probably become the surgery of the future. The aim of this paper is to present our preliminary experience with the three-arms "da Vinci S surgical system", to assess the feasibility of this technique in various abdominal and thoracic procedures and to point out the advantages of the robotic approach for each type of procedure. Between 18 January 2008 and 18 January 2009 153 patients (66 men and 87 women; mean age 48,02 years, range 6 to 84 years) underwent robotic-assisted surgical procedures in our institution; we performed 129 abdominal and 24 thoracic procedures, as follows: one cholecystectomy, 14 myotomies with Dor fundoplication, one gastroenteroanastomosis for unresectable antral gastric cancer, one transthoracic esophagectomy, 14 gastrectomies, one polypectomy through gastrotomy, 22 splenectomies,7 partial spleen resections, 22 thymectomy, 6 Nissen fundoplications, one Toupet fundoplication, one choledocho-duodeno-anastomosis, one drainage for pancreatic abscess, one distal pancreatectomy, one hepatic cyst fenestration, 7 hepatic resections, 29 colonic and rectal resections, 5 adrenalectomies, 12 total radical hysterectomies and pelvic lymphadenectomy, 3 hysterectomies with bilateral adnexectomy for uterine fibroma, one unilateral adnexectomy, and 2 cases of cervico-mediastinal goitre resection. 147 procedures were robotics completed , whereas 6 procedures were converted to open surgery due to the extent of the lesion. Average operating room time was 171 minutes (range 60 to 600 minutes, Median length of stay was 8,6 days (range 2 to 48 days). One system malfunctions was registered. Post-operatory complications occurred in 14 cases. There were no deaths. Our preliminary experience suggests that robotic surgery is feasible and worth of clinical application. The best indications for robotic surgery are the procedures that require a small operating field, a fine a precise dissection (suitable for pelvic and gastric lymphadenectomy, nerve sparing in total mesorectal excision) and safe intracorporeal sutures.

Sentinel lymph node biopsy under fluorescent indocyanin green guidance: Initial experience

PubMed Central

Aydoğan, Fatih; Arıkan, Akif Enes; Aytaç, Erman; Velidedeoğlu, Mehmet; Yılmaz, Mehmet Halit; Sager, Muhammet Sait; Çelik, Varol; Uras, Cihan

2016-01-01

Objective: Sentinel lymph node biopsy can be applied by using either blue dye or radionuclide method or both in breast cancer. Fluorescent imaging with indocyanine green is a new defined method. This study evaluates the applicability of sentinel lymph node biopsy via fluorescent indocyanine green. Material and Methods: IC-VIEW (Pulsion Medical Systems AG, Munich, Germany) infrared visualization system was used for imaging. Two mL of indocyanine green was injected to visualize sentinel lymph nodes. After injection, subcutaneous lymphatics were traced and sentinel lymph nodes were found with simultaneous imaging. Sentinel lymph nodes were excised under fluorescent light guidance, and excised lymph nodes were examined histopathologically. Patients with sentinel lymph node metastases underwent axillary dissection. Results: Four patients with sentinel lymph node biopsy due to breast cancer were included in the study. Sentinel lymph nodes were visualized with indocyanine green in all patients. The median number of excised sentinel lymph node was 2 (2–3). Two patients with lymph node metastasis underwent axillary dissection. No metastasis was detected in lymph nodes other than the sentinel nodes in patients with axillary dissection. There was no complication during and after the operation related to the method. Conclusion: According to our limited experience, sentinel lymph node biopsy under fluorescent indocyanine green guidance, which has an advantage of simultaneous visualization, is technically feasible. PMID:26985159

Dexterity optimization by port placement in robot-assisted minimally invasive surgery

NASA Astrophysics Data System (ADS)

Selha, Shaun; Dupont, Pierre; Howe, Robert D.; Torchiana, David F.

2002-02-01

A computer-based algorithm has been developed which uses preoperative images to provide a surgeon with a list of feasible port triplets ranked according to tool dexterity and endoscopic view quality at each surgical site involved in a procedure. A computer simulation allows the surgeon to select from among the proposed port locations. The procedure selected for the development of the system consists of a coronary artery bypass graft (CABG). In this procedure, the interior mammary artery (IMA) is mobilized from the interior chest wall, and one end is attached to the coronary arteries to provide a new blood supply for the heart. Approximately 10-20 cm is dissected free, using blunt dissection and a harmonic scalpel or electrocautery. At present, the port placement system is being evaluated in clinical trials.

Efficacy of Sentinel Lymph Node Biopsy in Detecting Axillary Metastasis in Breast Cancer Using Methylene Blue.

PubMed

Nandu, Vipul V; Chaudhari, Milind S

2017-06-01

Breast cancer is the leading malignancy and the second leading cause of cancer-related deaths. Axillary lymph node status is a very important prognostic factor in breast cancer patients; nodal evaluation is therefore a critical part of breast cancer management. Axillary lymph node dissection results in significant morbidity. Sentinel lymph node biopsy (SLNB) is being used in many centers to stage the axilla in planning axillary dissection management of patients and hence plays an important part in reducing morbidity among patients with carcinoma breast. The objectives of this paper is to study the (1) efficacy of sentinel lymph node biopsy in detecting axillary metastasis, (2) location of sentinel lymph node in the axilla, (3) rate of involvement of sentinel lymph nodes, and (4) incidence of skip metastasis. Thirty-five patients with breast cancer with clinically node-negative axilla were selected for the study. Methylene blue dye was injected intralesional and perilesional 20 min prior to surgery. All patients underwent modified radical mastectomy with sentinel lymph node biopsy and axillary dissection and after pathological examination diagnostic statics, namely sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and accuracy were computed. Sentinel lymph node was identified in all of these patients. Sixty percent patients had pathologically positive lymph nodes in the axilla. 90.48% patients of these had sentinel lymph nodes positive for malignant cells. Incidence of skip metastasis is 9.52%. 88.57% patients had sentinel lymph node mapped to level I lymph nodes. Sensitivity of SLNB is 90.48%, specificity is 85.71%, PPV of is 90.48%, NPV is 85.71%, and accuracy is 88.57%. Sentinel lymph node biopsy is an effective method of staging the axilla and deciding on axillary clearance in patients of carcinoma breast. Unnecessary axillary dissection and associated complications can be prevented in most of patients due to sentinel lymph node biopsy.

Robotic surgery for rectal cancer: a single center experience of 100 consecutive cases.

PubMed

Stănciulea, O; Eftimie, M; David, L; Tomulescu, V; Vasilescu, C; Popescu, I

2013-01-01

Minimally invasive techniques have revolutionized the field of general surgery over the few last decades. Despite its advantages, in complex procedures such as rectal surgery, laparoscopy has not achieved a high penetration rate because of its steep learning curve, its relatively high conversion rate and technical challenges. The aim of this study was to present a single center experience with robotic surgery for rectal cancer focusing mainly on early and mid-term postoperative outcome. A series of 100 consecutive patients who underwent robotic rectal surgery between January 2008 and June 2012 was analyzed retrospectively in terms of demographics, pathological data, surgical and oncological outcomes. Seventy-seven patients underwent robotic sphincter-saving resection, and 23 patients underwent robotic abdominoperineal resection. There were 4 conversions. The median operative time for sphincter-saving procedures was 180 min. The median time for robotic abdominoperineal resection was 160 min. The median distal resection margin of the operative specimen was 3 cm. The median number of retrieved lymph nodes was 14. The median hospital stay was 10 days. In-hospital mortality was nil. The overall morbidity was 30%. Four patients presented transitory postoperative urinary dysfunction. Severe erectile dysfunction was reported by 3 patients. The median length of follow-up was 24 months. The 3-year overall survival rate was 90%. Robotic surgery is advantageous for both surgeons (in that it facilitates dissection in a narrow pelvis) and patients (in that it affords a very good quality of life via the preservation of sexual and urinary function in the vast majority of patients and it has low morbidity and good midterm oncological outcomes). In rectal cancer surgery, the robotic approach is a promising alternative and is expected to overcome the low penetration rate of laparoscopy in this field. Celsius.

Evaluating the learning curve for robot-assisted laparoscopic radical cystectomy.

PubMed

Pruthi, Raj S; Smith, Angela; Wallen, Eric M

2008-11-01

We seek to describe the learning curve of robot-assisted laparoscopic radical cystectomy by evaluating some of the surgical, oncologic, and clinical outcomes in our initial experience with 50 consecutive patients undergoing this novel procedure. Fifty consecutive patients (representing our initial experience with robot-assisted cystectomy) underwent radical cystectomy and urinary diversion from January 2006 to December 2007. Several different metrics were used to evaluate the learning curve of this procedure, including estimated blood loss (EBL), operative (OR) time, pathologic outcomes, and complication rate. We evaluated patients as a continuous variable, divided into five distinct time periods (quintiles), and stratified by first half and second half of robotic experience. EBL was not significantly lower until the third quintile (patients 21-30), after which further significant reductions were not observed. Mean OR time declined between each quintile for the first 30 patients (1-10 v 11-20 v 21-30). No significant declines occurred after the third quintile (21-30). When evaluated as a continuous variable, the statistical cut point at which no further significant reductions were observed was after patient 20 for OR time. No differences were observed with regard to time to flatus, bowel movement, or hospital discharge. Furthermore, complications were not different between the initial 25 patients and the most recent patients. There has been no case of a positive margin, and there was only one inadvertent bladder entry. Lymph node yield has also not significantly changed over time. This report helps to define the learning curve associated with robot-assisted laparoscopic radical cystectomy for bladder cancer. Despite the higher OR times and blood loss that is observed early in the learning curve, no such compromises are observed with regard to these oncologic parameters even early in the experience.

Harmonic focus versus electrocautery in axillary lymph node dissection for breast cancer: a randomized clinical study.

PubMed

He, Qingqing; Zhuang, Dayong; Zheng, Luming; Fan, Ziyi; Zhou, Peng; Zhu, Jian; Lv, Zhen; Chai, Jixin; Cao, Lei

2012-12-01

Electrocautery has been proven to be associated with prolonged serous drainage that might result in several complications in patients requiring axillary lymph node dissection for breast cancer. We proposed that the Harmonic Focus might outperform electrocautery in axillary lymph node dissection, resulting in shorter operative times and reduced postoperative complications. One hundred twenty-eight women with confirmed T1-3 N1-2 breast cancer were randomly assigned to undergo mastectomy or breast-conserving surgery with axillary dissection by using Harmonic Focus or electrocautery. Sixty-four has surgery with Harmonic Focus (group A) and 64 with electrocautery (group B) by the same surgical team. Operative time, blood loss, total drainage volume and days, incidence of seroma, hematoma, pain score, and flap necrosis were recorded. Using Harmonic Focus significantly diminished operative time, blood loss, total drainage volume, days of stay, and visual analogue scale as compared with traditional electrocautery. There was no statistical difference between the 2 groups regarding seroma, hematoma, and flap necrosis. Axillary lymph node dissection using Harmonic Focus is feasible, safe, and a more comfortable design for the surgeon. Copyright © 2012 Elsevier Inc. All rights reserved.

Comparison of five systems for staging lymph node metastasis in gastric cancer.

PubMed

Yu, W; Choi, G S; Whang, I; Suh, I S

1997-09-01

There are several systems for staging lymph node metastasis in gastric cancer. Their relative merits are not clear. In this retrospective analysis, the nodal status was classified according to the Union Internacional Contra la Cancrum (UICC) and Japanese staging systems, the number and frequency of lymph node metastasis, and the level of involved nodes. Each staging system was scored as good (+1), fair (0) or poor (-1) with respect to prognostic value, theoretical value, convenience, reproducibility and surgical applicability. There were no differences between the five staging systems in predicting survival. The Japanese staging system was most arbitrary owing to the complexity of the system, although it had an advantage in surgical application. The same disadvantage was found in the UICC system and the level system. Determination of the number and frequency of involved nodes was convenient and reproducible, but the number of lymph nodes dissected must be considered when the number of positive nodes is used for staging. The classification of metastasis to the regional lymph nodes as N0 (no nodal metastasis), N1 (metastasis in 1-25 per cent of dissected nodes) and N2 (metastasis in more than 25 per cent of dissected nodes) would be a simple, convenient, reproducible staging system with an ability to predict surgical results.

Current role of minimally invasive approaches in the treatment of early gastric cancer

PubMed Central

El-Sedfy, Abraham; Brar, Savtaj S; Coburn, Natalie G

2014-01-01

Despite declining incidence, gastric cancer remains one of the most common cancers worldwide. Early detection in population-based screening programs has increased the number of cases of early gastric cancer, representing approximately 50% of newly detected gastric cancer cases in Asian countries. Endoscopic mucosal resection and endoscopic submucosal dissection have become the preferred therapeutic techniques in Japan and Korea for the treatment of early gastric cancer patients with a very low risk of lymph node metastasis. Laparoscopic and robotic resections for early gastric cancer, including function-preserving resections, have propagated through advances in technology and surgeon experience. The aim of this paper is to discuss the recent advances in minimally invasive approaches in the treatment of early gastric cancer. PMID:24833843

Can Teamwork and High-Volume Experience Overcome Challenges of Lymphadenectomy in Morbidly Obese Patients (Body Mass Index of 40 kg/m2 or Greater) with Endometrial Cancer?: A Cohort Study of Robotics and Laparotomy and Review of Literature.

PubMed

Fornalik, Hubert; Zore, Temeka; Fornalik, Nicole; Foster, Todd; Katschke, Adrian; Wright, Gary

2018-06-01

This study aimed to compare surgical outcomes and the adequacy of surgical staging in morbidly obese women with a body mass index (BMI) of 40 kg/m or greater who underwent robotic surgery or laparotomy for the staging of endometrioid-type endometrial cancer. This is a retrospective cohort study of patients who underwent surgical staging between May 2011 and June 2014. Patients' demographics, surgical outcomes, intraoperative and postoperative complications, and pathological outcomes were compared. Seventy-six morbidly obese patients underwent robotic surgery, and 35 underwent laparotomy for surgical staging. Robotic surgery was associated with more lymph nodes collected with increasing BMI (P < 0.001) and decreased chances for postoperative respiratory failure and intensive care unit admissions (P = 0.03). Despite a desire to comprehensively stage all patients, we performed successful pelvic and paraaortic lymphadenectomy in 96% versus 89% (P = 0.2) and 75% versus 60% (P = 0.12) of robotic versus laparotomy patients, respectively. In the robotic group, with median BMI of 47 kg/m, no conversions to laparotomy occurred. The robotic group experienced less blood loss and a shorter length of hospital stay than the laparotomy group; however, the surgeries were longer. In a high-volume center, a high rate of comprehensive surgical staging can be achieved in patients with BMI of 40 kg/m or greater either by laparotomy or robotic approach. In our experience, robotic surgery in morbidly obese patients is associated with better quality staging of endometrial cancer. With a comprehensive approach, a professional bedside assistant, use of a monopolar cautery hook, and our protocol of treating morbidly obese patients, robotic surgeries can be safely performed in the vast majority of patients with a BMI of 40 kg/m or greater, with lymph node counts being similar to nonobese patients, and with conversions to laparotomy reduced to a minimum.

Prognostic Value of Lymph Node Yield and Density in Head and Neck Malignancies.

PubMed

Cheraghlou, Shayan; Otremba, Michael; Kuo Yu, Phoebe; Agogo, George O; Hersey, Denise; Judson, Benjamin L

2018-06-01

Objective Studies have suggested that the lymph node yield and lymph node density from selective or elective neck dissections are predictive of patient outcomes and may be used for patient counseling, treatment planning, or quality measurement. Our objective was to systematically review the literature and conduct a meta-analysis of studies that investigated the prognostic significance of lymph node yield and/or lymph node density after neck dissection for patients with head and neck cancer. Data Sources The Ovid/Medline, Ovid/Embase, and NLM PubMed databases were systematically searched on January 23, 2017, for articles published between January 1, 1946, and January 23, 2017. Review Methods We reviewed English-language original research that included survival analysis of patients undergoing neck dissection for a head and neck malignancy stratified by lymph node yield and/or lymph node density. Study data were extracted by 2 independent researchers (S.C. and M.O.). We utilized the DerSimonian and Laird random effects model to account for heterogeneity of studies. Results Our search yielded 350 nonduplicate articles, with 23 studies included in the final synthesis. Pooled results demonstrated that increased lymph node yield was associated with a significant improvement in survival (hazard ratio, 0.833; 95% CI, 0.790-0.879). Additionally, we found that increased lymph node density was associated with poorer survival (hazard ratio, 1.916; 95% CI, 1.637-2.241). Conclusions Increased nodal yield portends improved outcomes and may be a valuable quality indicator for neck dissections, while increased lymph node density is associated with diminished survival and may be used for postsurgical counseling and planning for adjuvant therapy.

Clinical significance of prophylactic central compartment neck dissection in the treatment of clinically node-negative papillary thyroid cancer patients.

PubMed

Gambardella, Claudio; Tartaglia, Ernesto; Nunziata, Anna; Izzo, Graziella; Siciliano, Giuseppe; Cavallo, Fabio; Mauriello, Claudio; Napolitano, Salvatore; Thomas, Guglielmo; Testa, Domenico; Rossetti, Gianluca; Sanguinetti, Alessandro; Avenia, Nicola; Conzo, Giovanni

2016-09-19

Lymph nodal involvement is very common in differentiated thyroid cancer, and in addition, cervical lymph node micrometastases are observed in up to 80 % of papillary thyroid cancers. During the last decades, the role of routine central lymph node dissection (RCLD) in the treatment of papillary thyroid cancer (PTC) has been an object of research, and it is now still controversial. Nevertheless, many scientific societies and referral authors have definitely stated that even if in expert hands, RCLD is not associated to higher morbidity; it should be indicated only in selected cases. In order to better analyze the current role of prophylactic neck dissection in the surgical treatment of papillary thyroid cancers, an analysis of the most recent literature data was performed. Prophylactic or therapeutic lymph node dissection, selective, lateral or central lymph node dissection, modified radical neck dissection, and papillary thyroid cancer were used by the authors as keywords performing a PubMed database research. Literature reviews, PTCs large clinical series and the most recent guidelines of different referral endocrine societies, inhering neck dissection for papillary thyroid cancers, were also specifically evaluated. A higher PTC incidence was nowadays reported in differentiated thyroid cancer (DTC) clinical series. In addition, ultrasound guided fine-needle aspiration citology allowed a more precocious diagnosis in the early phases of disease. The role of prophylactic neck dissection in papillary thyroid cancer management remains controversial especially regarding indications, approach, and surgical extension. Even if morbidity rates seem to be similar to those reported after total thyroidectomy alone, RCLD impact on local recurrence and long-term survival is still a matter of research. Nevertheless, only a selective use in high-risk cases is supported by more and more scientific data. In the last years, higher papillary thyroid cancer incidence and more precocious diagnoses were worldwide reported. Among endocrine and neck surgeons, there is agreement about indications to prophylactic treatment of node-negative "high-risk" patients. A recent trend toward RCLD avoiding radioactive treatment is still debated, but nevertheless, prophylactic dissections in low-risk cases should be avoided. Prospective randomized trials are needed to evaluate the benefits of different approaches and allow to drawn definitive conclusions.

Resection in the popliteal fossa for metastatic melanoma.

PubMed

Marone, Ugo; Caracò, Corrado; Chiofalo, Maria Grazia; Botti, Gerardo; Mozzillo, Nicola

2007-01-19

Traditionally metastatic melanoma of the distal leg and the foot metastasize to the lymph nodes of the groin. Sometimes the first site of nodal disease can be the popliteal fossa. This is an infrequent event, with rare reports in literature and when it occurs, radical popliteal node dissection must be performed. We report a case of a 36-year old man presented with diagnosis of 2 mm thick, Clark's level II-III, non ulcerated melanoma of the left heel, which developed during the course of the disease popliteal node metastases, after a superficial and deep groin dissection for inguinal node involvement. Five months after popliteal lymph node dissection he developed systemic disease, therefore he received nine cycles of dacarbazine plus fotemustine. To date (56 months after prior surgery and 11 months after chemotherapy) he is alive with no evidence of disease. In case of groin metastases from melanoma of distal lower extremities, clinical and ultrasound examination of ipsilateral popliteal fossa is essential. When metastatic disease is found, radical popliteal dissection is the standard of care. Therefore knowledge of anatomy and surgical technique about popliteal lymphadenectomy are required to make preservation of structures that if injured, can produce a permanent, considerable disability.

Resection in the popliteal fossa for metastatic melanoma

PubMed Central

Marone, Ugo; Caracò, Corrado; Chiofalo, Maria Grazia; Botti, Gerardo; Mozzillo, Nicola

2007-01-01

Background Traditionally metastatic melanoma of the distal leg and the foot metastasize to the lymph nodes of the groin. Sometimes the first site of nodal disease can be the popliteal fossa. This is an infrequent event, with rare reports in literature and when it occurs, radical popliteal node dissection must be performed. Case presentation We report a case of a 36-year old man presented with diagnosis of 2 mm thick, Clark's level II-III, non ulcerated melanoma of the left heel, which developed during the course of the disease popliteal node metastases, after a superficial and deep groin dissection for inguinal node involvement. Five months after popliteal lymph node dissection he developed systemic disease, therefore he received nine cycles of dacarbazine plus fotemustine. To date (56 months after prior surgery and 11 months after chemotherapy) he is alive with no evidence of disease. Conclusion In case of groin metastases from melanoma of distal lower extremities, clinical and ultrasound examination of ipsilateral popliteal fossa is essential. When metastatic disease is found, radical popliteal dissection is the standard of care. Therefore knowledge of anatomy and surgical technique about popliteal lymphadenectomy are required to make preservation of structures that if injured, can produce a permanent, considerable disability. PMID:17239242

Feasibility of four-arm robotic lobectomy as solo surgery in patients with clinical stage I lung cancer.

PubMed

Park, Seong Yong; Suh, Jee Won; Narm, Kyoung Sik; Lee, Chang Young; Lee, Jin Gu; Paik, Hyo Chae; Chung, Kyoung Young; Kim, Dae Joon

2017-06-01

This study was performed to investigate the feasibility of four-arm robotic lobectomy (FARL) as a solo surgical technique in patients with non-small cell lung cancer (NSCLC). Early outcome and long-term survival of FARL were compared with those of video-assisted thoracoscopic lobectomy (VATL). Prospective enrollment of patients with clinical stage I NSCLC undergoing FARL or VATL (20 patients in each group) was planned. Interim analysis for early postoperative outcome was performed after the initial 10 cases in each group. The study was terminated early because of safety issues in the FARL group after enrollment of 12 FARL and 17 VATL patients from 2011 to 2012. There were no differences in clinical characteristics between groups. Lobectomy time and total operation time were significantly longer in the FARL group (P=0.003). There were three life-threatening events in the FARL group (2 bleedings, 1 bronchus tear) that necessitated thoracotomy conversion in 1 patient. There were no differences in other operative outcomes including pain score, complications, or length of hospital stay. Pathologic stage and number of dissected lymph nodes (LNs) were also comparable. During a follow-up of 48.9±9.5 months, recurrence was identified in 2 (16.7%) patients in FARL group and 3 (23.5%) in VATL group. Five-year overall survival (100% vs . 87.5%, P=0.386) and disease-free survival (82.5% vs . 75.6%, P=0.589) were comparable. FARL as solo surgery could not be recommended because of safety issues. It required a longer operation time and had no benefits over VATL in terms of early postoperative outcome or long-term survival.

Black sentinel lymph node and 'scary stickers'.

PubMed

Yang, Arthur S; Creagh, Terrence A

2013-04-01

An unusual case is presented of a young adult patient with two black-stained, radio-nucleotide tracer-active sentinel lymph nodes biopsied following her primary cutaneous melanoma treatment. This was subsequently confirmed to be secondary to cutaneous tattoos, averting the need of an elective regional node dissection. History of tattooing and tattoo removal should therefore be obtained as a routine in all melanoma patients considered for sentinel node biopsy (SLN). SLN biopsy and any subsequent completion node dissection should be strictly staged so that proper histologic diagnosis of the sentinel node is available for correct decision making and treatment. Copyright © 2012 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.

Comparison of 68Ga-PSMA-11 PET-CT with mpMRI for preoperative lymph node staging in patients with intermediate to high-risk prostate cancer.

PubMed

Zhang, Qing; Zang, Shiming; Zhang, Chengwei; Fu, Yao; Lv, Xiaoyu; Zhang, Qinglei; Deng, Yongming; Zhang, Chuan; Luo, Rui; Zhao, Xiaozhi; Wang, Wei; Wang, Feng; Guo, Hongqian

2017-11-07

To evaluate the diagnostic value of 68 Ga-PSMA-11 PET-CT with multiparametric magnetic resonance imaging (mpMRI) for lymph node (LN) staging in patients with intermediate- to high-risk prostate cancer (PCa) undergoing radical prostatectomy (RP) with pelvic lymph node dissection (PLND). We retrospectively identified 42 consecutive patients with intermediate- to high-risk PCa according to D'Amico and without concomitant cancer. Preoperative 68 Ga-PSMA-11 PET-CT, pelvic mpMRI and subsequent robot assisted laparoscopic RP with PLND were performed in all patients. Among 42 patients assessed, the preoperative PSA value, Gleason score, pT stage and intraprostatic PCa volume of patients with LN metastases were all significantly higher than those without metastases (P = 0.029, 0.028, 0.004, respectively). The average maximum standardized uptake value (SUV) of 68 Ga-PSMA-11 PET-CT positive PCa of patients with or without LN metastases were 13.10 (range 6.12-51.75) and 7.22 (range 5.4-11.2), respectively (P < 0.001). 68 Ga-PSMA-11 PET-CT and pelvic mpMRI had the ability of succeed on preoperative definite accurate diagnosis and accurate localization of primary PCa in all 42 patients. Fifteen patients (35.71%) had a pN1 stage. 51 positive LN were found. Both 68 Ga-PSMA-11 PET-CT and pelvic mpMRI displayed brillient patient-based and region-based sensitivity, specificity, negative predictive value and positive predictive value. There was no statistical difference for the detection of LNMs according to the diameter of the LNMs between 68 Ga-PSMA-11 PET-CT and mpMRI in this study. Both 68 Ga-PSMA-11 PET-CT and mpMRI performed great value for LN staging in patients with intermediate- to high-risk PCa undergoing RP with PLND. However, despite excellent performance of 68 Ga-PSMA-11 PET-CT, it cannot replace mpMRI that remains excellent for lymph node staging.

Sentinel Lymph Nodes for Breast Carcinoma: A Paradigm Shift.

PubMed

Maguire, Aoife; Brogi, Edi

2016-08-01

-Sentinel lymph node biopsy has been established as the new standard of care for axillary staging in most patients with invasive breast carcinoma. Historically, all patients with a positive sentinel lymph node biopsy result underwent axillary lymph node dissection. Recent trials show that axillary lymph node dissection can be safely omitted in women with clinically node negative, T1 or T2 invasive breast cancer treated with breast-conserving surgery and whole-breast radiotherapy. This change in practice also has implications on the pathologic examination and reporting of sentinel lymph nodes. -To review recent clinical and pathologic studies of sentinel lymph nodes and explore how these findings influence the pathologic evaluation of sentinel lymph nodes. -Sources were published articles from peer-reviewed journals in PubMed (US National Library of Medicine) and published guidelines from the American Joint Committee on Cancer, the Union for International Cancer Control, the American Society of Clinical Oncology, and the National Comprehensive Cancer Network. -The main goal of sentinel lymph node examination should be to detect all macrometastases (>2 mm). Grossly sectioning sentinel lymph nodes at 2-mm intervals and evaluation of one hematoxylin-eosin-stained section from each block is the preferred method of pathologic evaluation. Axillary lymph node dissection can be safely omitted in clinically node-negative patients with negative sentinel lymph nodes, as well as in a selected group of patients with limited sentinel lymph node involvement. The pathologic features of the primary carcinoma and its sentinel lymph node metastases contribute to estimate the extent of non-sentinel lymph node involvement. This information is important to decide on further axillary treatment.

A pilot study of lymph node mapping with indocyanine green in robotic gastrectomy for gastric cancer.

PubMed

Lan, Yuan-Tzu; Huang, Kuo-Hung; Chen, Ping-Hsien; Liu, Chien-An; Lo, Su-Shun; Wu, Chew-Wun; Shyr, Yi-Ming; Fang, Wen-Liang

2017-01-01

Robotic gastrectomy has become increasingly popular in the treatment of gastric cancer, especially in Asian countries. The use of indocyanine green fluorescence has been reported in lymphatic mapping for gastric cancer in laparoscopic gastrectomy; however, there have been few reports regarding the use of indocyanine green in robotic gastrectomy. From January 2011 to March 2016, a total of 79 patients underwent robotic gastrectomy for gastric cancer. Among them, intraoperative subserosal injection (n = 9) or preoperative submucosal injection (n = 5) of indocyanine green with near-infrared imaging was performed in 14 patients, and the other 65 patients underwent robotic gastrectomy without the use of indocyanine green. There was no significant difference in the operative time, total number of retrieved lymph nodes, operative blood loss, and postoperative hospital stay between the patients who underwent robotic gastrectomy with or without indocyanine green fluorescence. For each lymph node station, there was significantly more number of retrieved lymph nodes in the indocyanine green group than in the no-indocyanine green group at the greater curvature side of the low body (#4d) to the infrapyloric region (#6) of the stomach. Five of the 14 patients who received an indocyanine green injection for lymphatic mapping had lymph node metastasis, and metastatic lymph nodes were located in the lymph node stations as detected by indocyanine green fluorescence during surgery. Indocyanine green fluorescence with near-infrared imaging is feasible and is a promising method of lymphatic mapping in robotic gastrectomy for gastric cancer. In future studies, larger patient numbers and long-term follow-up are required.

Analgesic opioid dose is an important indicator of postoperative ileus following radical cystectomy with ileal conduit: experience in the robotic surgery era.

PubMed

Koo, Kyo Chul; Yoon, Young Eun; Chung, Byung Ha; Hong, Sung Joon; Rha, Koon Ho

2014-09-01

Postoperative ileus (POI) is common following bowel resection for radical cystectomy with ileal conduit (RCIC). We investigated perioperative factors associated with prolonged POI following RCIC, with specific focus on opioid-based analgesic dosage. From March 2007 to January 2013, 78 open RCICs and 26 robot-assisted RCICs performed for bladder carcinoma were identified with adjustment for age, gender, American Society of Anesthesiologists grade, and body mass index (BMI). Perioperative records including operative time, intraoperative fluid excess, estimated blood loss, lymph node yield, and opioid analgesic dose were obtained to assess their associations with time to passage of flatus, tolerable oral diet, and length of hospital stay (LOS). Prior to general anaesthesia, patients received epidural patient-controlled analgesia (PCA) consisted of fentanyl with its dose adjusted for BMI. Postoperatively, single intravenous injections of tramadol were applied according to patient desire. Multivariate analyses revealed cumulative dosages of both PCA fentanyl and tramadol injections as independent predictors of POI. According to surgical modality, linear regression analyses revealed cumulative dosages of PCA fentanyl and tramadol injections to be positively associated with time to first passage of flatus, tolerable diet, and LOS in the open RCIC group. In the robot-assisted RCIC group, only tramadol dose was associated with time to flatus and tolerable diet. Compared to open RCIC, robot-assisted RCIC yielded shorter days to diet and LOS; however, it failed to shorten days to first flatus. Reducing opioid-based analgesics shortens the duration of POI. The utilization of the robotic system may confer additional benefit.

Sentinel node localization in oral cavity and oropharynx squamous cell cancer.

PubMed

Taylor, R J; Wahl, R L; Sharma, P K; Bradford, C R; Terrell, J E; Teknos, T N; Heard, E M; Wolf, G T; Chepeha, D B

2001-08-01

To evaluate the feasibility and predictive ability of the sentinel node localization technique for patients with squamous cell carcinoma of the oral cavity or oropharynx and clinically negative necks. Prospective, efficacy study comparing the histopathologic status of the sentinel node with that of the remaining neck dissection specimen. Tertiary referral center. Patients with T1 or T2 disease and clinically negative necks were eligible for the study. Nine previously untreated patients with oral cavity or oropharyngeal squamous cell carcinoma were enrolled in the study. Unfiltered technetium Tc 99m sulfur colloid injections of the primary tumor and lymphoscintigraphy were performed on the day before surgery. Intraoperatively, the sentinel node(s) was localized with a gamma probe and removed after tumor resection and before neck dissection. The primary outcome was the negative predictive value of the histopathologic status of the sentinel node for predicting cervical metastases. Sentinel nodes were identified in 9 previously untreated patients. In 5 patients, there were no positive nodes. In 4 patients, the sentinel nodes were the only histopathologically positive nodes. In previously untreated patients, the sentinel node technique had a negative predictive value of 100% for cervical metastasis. Our preliminary investigation shows that sentinel node localization is technically feasible in head and neck surgery and is predictive of cervical metastasis. The sentinel node technique has the potential to decrease the number of neck dissections performed in clinically negative necks, thus reducing the associated morbidity for patients in this group.

Lymph Node Metastases and Prognosis in Left Upper Division Non-Small Cell Lung Cancers: The Impact of Interlobar Lymph Node Metastasis

PubMed Central

Kuroda, Hiroaki; Sakao, Yukinori; Mun, Mingyon; Uehara, Hirofumi; Nakao, Masayuki; Matsuura, Yousuke; Mizuno, Tetsuya; Sakakura, Noriaki; Motoi, Noriko; Ishikawa, Yuichi; Yatabe, Yasushi; Nakagawa, Ken; Okumura, Sakae

2015-01-01

Background Left upper division segmentectomy is one of the major pulmonary procedures; however, it is sometimes difficult to completely dissect interlobar lymph nodes. We attempted to clarify the prognostic importance of hilar and mediastinal nodes, especially of interlobar lymph nodes, in patients with primary non-small cell lung cancer (NSCLC) located in the left upper division. Methods We retrospectively studied patients with primary left upper lobe NSCLC undergoing surgical pulmonary resection (at least lobectomy) with radical lymphadenectomy. The representative evaluation of therapeutic value from the lymph node dissection was determined using Sasako’s method. This analysis was calculated by multiplying the frequency of metastasis to the station and the 5-year survival rate of the patients with metastasis to the station. Results We enrolled 417 patients (237 men, 180 women). Tumors were located in the lingular lobe and at the upper division of left upper lobe in 69 and 348 patients, respectively. The pathological nodal statuses were pN0 in 263 patients, pN1 in 70 patients, and pN2 in 84 patients. Lymph nodes #11 and #7 were significantly correlated with differences in node involvement in patients with left upper lobe NSCLC. Among those with left upper division NSCLC, the 5-year overall survival in pN1 was 31.5% for #10, 39.3% for #11, and 50.4% for #12U. The involvement of node #11 was 1.89-fold higher in the anterior segment than that in the apicoposterior segment. The therapeutic index of estimated benefit from lymph node dissection for #11 was 3.38, #4L was 1.93, and the aortopulmonary window was 4.86 in primary left upper division NSCLC. Conclusions Interlobar node involvement is not rare in left upper division NSCLC, occurring in >20% cases. Furthermore, dissection of interlobar nodes was found to be beneficial in patients with left upper division NSCLC. PMID:26247881

The Value of Sentinel Lymph Node Biopsy in Oral Cavity Cancers

PubMed Central

Kaya, İsa; Göde, Sercan; Öztürk, Kerem; Turhal, Göksel; Aliyev, Araz; Akyıldız, Serdar; Duygun, Ülkem Yararbaş; Uluöz, Ümit; Yavuzer, Atilla

2015-01-01

Objective The aim of this study was to establish the effectiveness of sentinel lymph node biopsy in the detection of metastasis in N0 necks of T1–T2 early-stage oral cavity cancers. Materials and Methods Twenty neck dissections were performed in 18 patients diagnosed with T1 and T2 oral cavity cancer, with an indication for elective neck dissection between November 2007 and January 2011. The male to female ratio was 12:8, with a mean age of 54.5 years (range 28–76). Eight of the dissections were performed for lower lip cancer, 7 for tongue cancer, and 5 for floor of the mouth cancer. Sentinel lymph node biopsy was used to detect metastatic lymph nodes. Tc99m radionuclide injection was administered to the periphery of the tumor 24 h before the operation, and a lymphoscintigraphy image was obtained 30 min after the injection. Sentinel lymph nodes were localized and excised on the day of surgery using static lymphoscintigraphy images and a gamma probe. Sentinel lymph nodes were sent for a frozen section examination, and either a selective or a comprehensive neck dissection was performed for each neck according to the results. Results After the final histopathological examination of the specimens, the negative predictive value, the positive predictive value, the accuracy of the sentinel lymph node biopsy, and frozen section accuracy were found to be 100%. Conclusion Sentinel lymph node biopsy was found to be an efficient method in the pathological staging and management of the N0 neck in early T-stage oral cavity cancers. PMID:29391982

Port-site metastases following robot-assisted laparoscopic surgery for gynecological malignancies.

PubMed

Lönnerfors, Celine; Bossmar, Thomas; Persson, Jan

2013-12-01

To evaluate the incidence and possible predictors associated with port-site metastases following robotic surgery. Prospective study. University Hospital. Women with gynecological cancer. The occurrence of port-site metastases in the first 475 women undergoing robotic surgery for gynecological cancer was reviewed. Rate of port-site metastases. A port-site metastasis was detected in nine of 475 women (1.9%). Eight women had either an unexpected locally advanced disease or lymph-node metastases at the time of surgery. All nine women received postoperative adjuvant therapy. Women with ≥ stage III endometrial cancer and women with node positive cervical cancer had a significantly higher risk of developing a port-site metastasis, as did women with high-risk histology endometrial cancer. Port-site metastases were four times more likely to occur in a specimen-retrieval port. One (0.2%) isolated port-site metastasis was detected. The median time to occurrence of a port-site metastasis was 6 months (range 2-19 months). Six of the nine women (67%) have died and their median time of survival from recurrence was 4 months (range 2-16 months). In women with gynecological cancer, the incidence of port-site metastases following robotic surgery was 1.9%. High-risk histology and/or advanced stage of disease at surgery seem to be contributing factors. © 2013 Nordic Federation of Societies of Obstetrics and Gynecology.

Rice-obot 1: An intelligent autonomous mobile robot

NASA Technical Reports Server (NTRS)

Defigueiredo, R.; Ciscon, L.; Berberian, D.

1989-01-01

The Rice-obot I is the first in a series of Intelligent Autonomous Mobile Robots (IAMRs) being developed at Rice University's Cooperative Intelligent Mobile Robots (CIMR) lab. The Rice-obot I is mainly designed to be a testbed for various robotic and AI techniques, and a platform for developing intelligent control systems for exploratory robots. Researchers present the need for a generalized environment capable of combining all of the control, sensory and knowledge systems of an IAMR. They introduce Lisp-Nodes as such a system, and develop the basic concepts of nodes, messages and classes. Furthermore, they show how the control system of the Rice-obot I is implemented as sub-systems in Lisp-Nodes.

Can Teamwork and High-Volume Experience Overcome Challenges of Lymphadenectomy in Morbidly Obese Patients (Body Mass Index of 40 kg/m2 or Greater) with Endometrial Cancer?

PubMed Central

Fornalik, Hubert; Zore, Temeka; Fornalik, Nicole; Foster, Todd; Katschke, Adrian; Wright, Gary

2018-01-01

Objective This study aimed to compare surgical outcomes and the adequacy of surgical staging in morbidly obese women with a body mass index (BMI) of 40 kg/m2 or greater who underwent robotic surgery or laparotomy for the staging of endometrioid-type endometrial cancer. Methods This is a retrospective cohort study of patients who underwent surgical staging between May 2011 and June 2014. Patients' demographics, surgical outcomes, intraoperative and postoperative complications, and pathological outcomes were compared. Results Seventy-six morbidly obese patients underwent robotic surgery, and 35 underwent laparotomy for surgical staging. Robotic surgery was associated with more lymph nodes collected with increasing BMI (P < 0.001) and decreased chances for postoperative respiratory failure and intensive care unit admissions (P = 0.03). Despite a desire to comprehensively stage all patients, we performed successful pelvic and paraaortic lymphadenectomy in 96% versus 89% (P = 0.2) and 75% versus 60% (P = 0.12) of robotic versus laparotomy patients, respectively. In the robotic group, with median BMI of 47 kg/m2, no conversions to laparotomy occurred. The robotic group experienced less blood loss and a shorter length of hospital stay than the laparotomy group; however, the surgeries were longer. Conclusions In a high-volume center, a high rate of comprehensive surgical staging can be achieved in patients with BMI of 40 kg/m2 or greater either by laparotomy or robotic approach. In our experience, robotic surgery in morbidly obese patients is associated with better quality staging of endometrial cancer. With a comprehensive approach, a professional bedside assistant, use of a monopolar cautery hook, and our protocol of treating morbidly obese patients, robotic surgeries can be safely performed in the vast majority of patients with a BMI of 40 kg/m2 or greater, with lymph node counts being similar to nonobese patients, and with conversions to laparotomy reduced to a minimum. PMID:29621128

[The incidence of human papilloma virus associated vulvar cancer in younger women is increasing and wide local excision with sentinel lymph node biopsie has become standard].

PubMed

Fehr, Mathias K

2011-10-01

Sentinel lymph node (SLN) dissections have been shown to be sensitive for the evaluation of nodal basins for metastatic disease and are associated with decreased short-term and long-term morbidity when compared with complete lymph node dissection. There has been increasing interest in the use of SLN technology in gynecologic cancers. This review assesses the current evidence-based literature for the use of SLN dissections in gynecologic malignancies. Recent literature continues to support the safety and feasibility of SLN biopsy for early stage vulvar cancer with negative predictive value approaching 100 % and low false negative rates. Alternatively, for endometrial cancer most studies have reported low false-negative rates, with variable sensitivities and have reported low detection rates of the sentinel node. Studies examining the utility of SLN biopsy in early-stage cervical cancer remain promising with detection rates, sensitivities, and false-negative rates greater than 90 % for stage 1B1 tumors. SLN dissections have been shown to be effective and safe in certain, select vulvar cancer patients and can be considered an alternative surgical approach for these patients. For endometrial and cervical cancer, SLN dissection continues to have encouraging results and however needs further investigation.

Sentinel node detection in pre-operative axillary staging.

PubMed

Trifirò, Giuseppe; Viale, Giuseppe; Gentilini, Oreste; Travaini, Laura Lavinia; Paganelli, Giovanni

2004-06-01

The concept of sentinel lymph node biopsy in breast cancer surgery is based on the fact that the tumour drains in a logical way via the lymphatic system, from the first to upper levels. Since axillary node dissection does not improve the prognosis of patients with breast cancer, sentinel lymph node biopsy might replace complete axillary dissection for staging of the axilla in clinically N0 patients. Sentinel lymph node biopsy would represent a significant advantage as a minimally invasive procedure, considering that about 70% of patients are found to be free from metastatic disease, yet axillary node dissection can lead to significant morbidity. Subdermal or peritumoural injection of small aliquots (and very low activity) of radiotracer is preferred to intratumoural administration, and (99m)Tc-labelled colloids with most of the particles in the 100-200 nm size range would be ideal for radioguided sentinel node biopsy in breast cancer. The success rate of radioguidance in localising the sentinel lymph node in breast cancer surgery is about 97% in institutions where a high number of procedures are performed, and the success rate of lymphoscintigraphy in sentinel node detection is about 100%. The sentinel lymph node should be processed for intraoperative frozen section examination in its entirety, based on conventional histopathology and, when necessary, immune staining with anti-cytokeratin antibody. Nowadays, lymphoscintigraphy is a useful procedure in patients with different clinical evidence of breast cancer.

Comparison of a gasless unilateral axillo-breast and axillary approach in robotic thyroidectomy.

PubMed

Song, Chang Myeon; Cho, Yong Hee; Ji, Yong Bae; Jeong, Jin Hyeok; Kim, Dong Sun; Tae, Kyung

2013-10-01

New approaches to robotic thyroidectomy help to prevent neck scarring and improve surgical ergonomics. The purpose of this study was to compare the efficacy and advantages of a gasless unilateral axillary (GUA) approach and an axillo-breast (GUAB) approach in robotic thyroidectomy. We retrospectively reviewed the data of 131 patients who underwent robotic thyroidectomy with or without central neck dissection using a GUAB (90 cases) or GUA (41 cases) approach between September 2009 and December 2011. We excluded patients who underwent simultaneous lateral neck dissection and cases within the learning curve. We compared patient and tumor characteristics, surgical outcomes, perioperative complications, and cosmetic satisfaction between the two approaches. Robotic thyroidectomy was successful in all patients. There were no differences in terms of patient and tumor characteristics, extent of thyroidectomy and central neck dissection, operative time, and postoperative complications between the two approaches. Cosmetic satisfaction was excellent in both groups. There was no difference in satisfaction with the cosmetic result in the neck area, but the GUA patients expressed higher satisfaction with the appearance of the breast. The surgical outcomes of GUA and GUAB approaches are similar in robotic thyroidectomy. Both are safe, effective, and yield cosmetically excellent results when performed by an experienced robotic thyroid surgeon. However, a GUA approach is associated with superior cosmetic satisfaction with the appearance of the breast.

Polar Seismic TETwalker: Integrating Engineering Teaching and Research

NASA Astrophysics Data System (ADS)

Gifford, C. M.; Ruiz, I.; Carmichael, B. L.; Wade, U. B.; Agah, A.

2007-12-01

Based on the TETwalker robot platform at NASA/Goddard Space Flight Center, the Center for Remote Sensing of Ice Sheets (CReSIS) has begun work on designing and modeling the integration of seismic surveying equipment into the TETwalker robot architecture for use in polar environments. Employing multiple Seismic TETwalker robots will allow gathering of polar seismic data in previously inaccessible or unexplored terrains, as well as help significantly reduce human involvement in such harsh environments. NASA's TETwalker mobile robot uses a unique form of mobility to topple across the surface and over obstacles. This robot therefore does not suffer the fate of other wheeled and tracked robots if tipped over. It is composed of extending struts and nodes, forming a tetrahedral shape which can be strategically adjusted to change the robot's center of gravity for toppling. Of the many platforms the TETwalker architecture can form, the 4-TETwalker robot (consisting of four ground nodes, a center payload node, and interconnecting struts) has been the focus of current research. The center node has been chosen as the geophone deployment medium, designed in such a way to allow geophone insertion using any face of the robot's structure. As the robot comes to rest at the deployment location, one of its faces will rest on the surface. No matter which side it is resting on, a geophone spike will be perpendicular to its face and an extending strut will be vertical for pushing the geophone into the ground. Lengthening and shortening struts allow the deployment node to precisely place the geophone into the ground, as well as vertically orient the geophones for proper data acquisition on non-flat surfaces. Power source integration has been investigated, incorporating possible combinations of solar, wind, and vibration power devices onboard the robot models for long-term survival in a polar environment. Designs have also been modeled for an alternate center node sensor package (e.g., broadband seismometer) and other structures of the node-and-strut TETwalker robot architecture. It is planned to take the design models and construct a physical prototype for future testing in Greenland and Antarctica. This work involved three undergraduate students from underrepresented groups as part of the CReSIS Summer REU program, aimed at involving these groups in science and engineering research.

Decline in Frozen Section Diagnosis for Axillary Sentinel Lymph Nodes as a Result of the American College of Surgeons Oncology Group Z0011 Trial.

PubMed

Bishop, Julie Anne; Sun, Jihong; Ajkay, Nicolas; Sanders, Mary Ann G

2016-08-01

-Results of the American College of Surgeons Oncology Group Z0011 trial showed that patients with early-stage breast cancer and limited sentinel node metastasis treated with breast conservation and systemic therapy did not benefit from axillary lymph node dissection. Subsequently, most pathology departments have likely seen a decrease in frozen section diagnosis of sentinel lymph nodes. -To determine the effect of the Z0011 trial on pathology practice and to examine the utility of intraoperative sentinel lymph node evaluation for this subset of patients. -Pathology reports from cases of primary breast cancer that met Z0011 clinical criteria and were initially treated with lumpectomy and sentinel lymph node biopsy from 2009 to 2015 were collected. Clinicopathologic data were recorded. -Sentinel lymph node biopsies sent for frozen section diagnosis occurred in 22 of 22 cases (100%) in 2009 and 15 of 22 cases (68%) in 2010 during the pre-Z0011 years, and in 3 of 151 cases (2%) collected in 2011 through 2015, considered to be post-Z0011 years. Of the 151 post-Z0011 cases, 28 (19%) had sentinel lymph nodes with metastasis, and 147 (97%) were spared axillary lymph node dissection. -Following Z0011, intraoperative sentinel lymph node evaluation has significantly decreased at our institution. Prior to surgery, all patients had clinically node-negative disease. After sentinel lymph node evaluation, 97% (147 of 151) of the patients were spared axillary lymph node dissection. Therefore, routine frozen section diagnosis for sentinel lymph node biopsies can be avoided in these patients.

Sentinel Lymph Nodes for Breast Carcinoma A Paradigm Shift

PubMed Central

Maguire, Aoife; Brogi, Edi

2016-01-01

Context Sentinel lymph node biopsy has been established as the new standard of care for axillary staging in most patients with invasive breast carcinoma. Historically, all patients with a positive sentinel lymph node biopsy result underwent axillary lymph node dissection. Recent trials show that axillary lymph node dissection can be safely omitted in women with clinically node negative, T1 or T2 invasive breast cancer treated with breast-conserving surgery and whole-breast radiotherapy. This change in practice also has implications on the pathologic examination and reporting of sentinel lymph nodes. Objective To review recent clinical and pathologic studies of sentinel lymph nodes and explore how these findings influence the pathologic evaluation of sentinel lymph nodes. Data Sources Sources were published articles from peer-reviewed journals in PubMed (US National Library of Medicine) and published guidelines from the American Joint Committee on Cancer, the Union for International Cancer Control, the American Society of Clinical Oncology, and the National Comprehensive Cancer Network. Conclusions The main goal of sentinel lymph node examination should be to detect all macrometastases (>2 mm). Grossly sectioning sentinel lymph nodes at 2-mm intervals and evaluation of one hematoxylin-eosin–stained section from each block is the preferred method of pathologic evaluation. Axillary lymph node dissection can be safely omitted in clinically node-negative patients with negative sentinel lymph nodes, as well as in a selected group of patients with limited sentinel lymph node involvement. The pathologic features of the primary carcinoma and its sentinel lymph node metastases contribute to estimate the extent of non–sentinel lymph node involvement. This information is important to decide on further axillary treatment. PMID:27472237

Radionavigated detection of sentinel nodes in breast carcinoma--first experiences of our department.

PubMed

Duchaj, B; Chvalny, P; Vesely, J; Makaiova, I; Durdik, S; Straka, V; Palaj, J; Procka, V; Aksamitova, K; Skraskova, S; Banki, P; Kovacova, S; Galbavy, S

2010-01-01

Biopsy and histological evaluation of sentinel lymphatic node limits the axillary node dissection only in cases of positive histological finding and decreases the occurrence of postoperative complications related to the axillary node dissection. We used radiotracer SentiScint, Medi-Radiopharma Ltd, Hungary and preoperatively administered blue dye--Blue Patenté V, Guebert, Aulnay-Sous-Bios, France. 11 (18%) patients were subdued to deep peritimorous application of radiotracer, 10 (16.4%) to sub/intradermal application over the lesions and n 40 (65.6%) patients the application was sub/intradermal and periareolar. The patients underwent an operation protocol of corresponding quadrantectomy, radionavigated blue-dye sentinel node biopsy and axillary dissection. From May 2006 to June 2008, we examined 61 patients with breast carcinoma. They underwent radionavigated and blue-dye sentinel node biopsy. We detected 57 (93.4%) sentinel nodes with preoperative scintigraphy, of which only 51 (83.6%) were detected peroperatively and underwent histological evaluation. In six (9.8%) cases, the "frozen cut" histology of the primary lesion had shown a benign lesion; hence no sentinel node biopsy or axillary disection was performed. 12 (19.7%) of 51 histologically evaluated sentinel nodes had metastatic invasion. We retrospectively compared the histological fund in sentinel and axillary nodes in patients with metastatic sentinel nodes. In 6 (16.6%) cases, the sentinel node was positive of metastatic invasion but axillary nodes were histologically negative, in 6 (16.6%) cases the sentinel node and axillary nodes were positive for metastatic invasion. We observed falsely negative findings in 3 (8.3%) patients with negative histological fund in the sentinel node, but positive axillary nodes (Tab. 3, Fig. 2, Ref. 11). Full Text (Free, PDF) www.bmj.sk.

Da Vinci robot-assisted anatomic left hemihepatectomy and biliary reconstruction.

PubMed

Wang, Zhifei; Liu, Quanda; Chen, Junzhou; Duan, Weihong; Zhou, Ningxin

2013-06-01

Since the introduction of Da Vinci robotic surgery, more and more complicated surgeries can now be performed robotically, yet there have been very few on robotic hepatectomy, especially when billiary reconstruction is involved. The video shows our initial experience with an anatomic hepatectomy using Da Vinci surgical robot. In this case, we also conducted billiary reconstruction due to the anatomic abnormality of bile duct, while applying the choledochoscopy. The preoperative diagnosis is primary liver carcinoma, tumor thrombi in bile duct, and hepatitis B. First, the gallbladder was resected, and cystic artery and duct were identified. After opening of the common bile duct above the junction, the choledochoscopy was performed. Tumor thrombi were found in common bile duct and left hepatic duct, and they were all removed. Left branches hepatic artery and portal vein were dissected, ligated, and divided. Thrombi in the left hepatic duct were removed also. After marking the cutting line along the ischemic boarder, liver parenchyma was transected using robotic harmonic scalpel. Branches of ducts were encountered and managed by either direct coagulating or dividing after clipping. The left hepatic vein was visualized, exposed, and divided during hepatectomy. Two T tubes were placed into common hepatic duct and the proximal cutting end of right anterior bile duct which was found to join the left hepatic duct, respectively. The operation went on successfully. The operation time was 410 minutes, the blood loss was 200 mL. The pathologic diagnosis was introductal papillary adenocarcinoma of left hepatic duct. The patient went on well postoperatively and was followed up for 22 months till now. Postoperative computed tomography examination showed no recurrence. Da Vinci-assisted robotic hepatectomy can be performed safely in the hands of experienced hepatobilliary surgeons, and choledochoscopy can be combined for bile duct exploration. With the advantages of Da Vinci robot system, complicated billiary reconstruction can be performed (http://links.lww.com/SLE/A74).

A simple 5-DOF walking robot for space station application

NASA Technical Reports Server (NTRS)

Brown, H. Benjamin, Jr.; Friedman, Mark B.; Kanade, Takeo

1991-01-01

Robots on the NASA space station have a potential range of applications from assisting astronauts during EVA (extravehicular activity), to replacing astronauts in the performance of simple, dangerous, and tedious tasks; and to performing routine tasks such as inspections of structures and utilities. To provide a vehicle for demonstrating the pertinent technologies, a simple robot is being developed for locomotion and basic manipulation on the proposed space station. In addition to the robot, an experimental testbed was developed, including a 1/3 scale (1.67 meter modules) truss and a gravity compensation system to simulate a zero-gravity environment. The robot comprises two flexible links connected by a rotary joint, with a 2 degree of freedom wrist joints and grippers at each end. The grippers screw into threaded holes in the nodes of the space station truss, and enable it to walk by alternately shifting the base of support from one foot (gripper) to the other. Present efforts are focused on mechanical design, application of sensors, and development of control algorithms for lightweight, flexible structures. Long-range research will emphasize development of human interfaces to permit a range of control modes from teleoperated to semiautonomous, and coordination of robot/astronaut and multiple-robot teams.

Postoperative staging of the neck dissection using extracapsular spread and lymph node ratio as prognostic factors in HPV-negative head and neck squamous cell carcinoma patients.

PubMed

Majercakova, Katarina; Valero, Cristina; López, Montserrat; García, Jacinto; Farré, Nuria; Quer, Miquel; León, Xavier

2018-02-01

The presence of nodes with extracapsular spread (ECS) and the lymph node ratio (LNR) have prognostic competence in the pathologic evaluation of patients with a head and neck squamous cell carcinoma (HNSCC) treated with a neck dissection. The purpose of this study is to assess the effect of ECS & LNR on prognosis of HPV negative HNSCC patients treated with neck dissection and to compare to 8th edition TNM/AJCC classification. We carried out a retrospective study of 1383 patients with HNSCC treated with a neck dissection between 1985 and 2013. We developed a classification of the patients according to the presence of nodes with ECS and the LNR value with a recursive partitioning analysis (RPA) model. We obtained a classification tree with four terminal nodes: for patients without ECS (including patients pN0) the cut-off point for LNR was 1.6%, while for patients with lymph nodes with ECS it was 11.4%. The 5-year disease-specific survival for patients without ECS/LNR < 1.6% was 83.3%; for patients without ECS/LNR ≥ 1.6% it was 61.5%; for patients with ECS/LNR < 11.4% it was 33.7%; and for patients with ECS/LNR ≥ 11.4% it was 18.5%. The classification obtained with RPA had better discrimination between categories than the 8th edition of the TNM/AJCC classification. ECS status and LNR value proved high prognostic capacity in the pathological evaluation of the neck dissection. The combination of ECS and LNR improved the predictive capacity of the 8th edition of the TNM/AJCC classification in HPV-negative HNSCC patients. Copyright © 2017 Elsevier Ltd. All rights reserved.

Applications of Evolving Robotic Technology for Head and Neck Surgery.

PubMed

Sharma, Arun; Albergotti, W Greer; Duvvuri, Umamaheswar

2016-03-01

Assess the use and potential benefits of a new robotic system for transoral radical tonsillectomy, transoral supraglottic laryngectomy, and retroauricular thyroidectomy in a cadaver dissection. Three previously described robotic procedures (transoral radical tonsillectomy, transoral supraglottic laryngectomy, and retroauricular thyroidectomy) were performed in a cadaver using the da Vinci Xi Surgical System. Surgical exposure and access, operative time, and number of collisions were examined objectively. The new robotic system was used to perform transoral radical tonsillectomy with dissection and preservation of glossopharyngeal nerve branches, transoral supraglottic laryngectomy, and retroauricular thyroidectomy. There was excellent exposure without any difficulties in access. Robotic operative times (excluding set-up and docking times) for the 3 procedures in the cadaver were 12.7, 14.3, and 21.2 minutes (excluding retroauricular incision and subplatysmal elevation), respectively. No robotic arm collisions were noted during these 3 procedures. The retroauricular thyroidectomy was performed using 4 robotic ports, each with 8 mm instruments. The use of updated and evolving robotic technology improves the ease of previously described robotic head and neck procedures and may allow surgeons to perform increasingly complex surgeries. © The Author(s) 2015.

Risk factors and the preoperative assessment of right para-oesophageal lymph node metastasis in right lobe papillary thyroid carcinoma: A case series.

PubMed

Qu, You; Zhang, Hao; Zhang, Ping; Dong, Wenwu; He, Liang; Sun, Wei; Liu, Jinhao

2017-06-01

Right para-oesophageal lymph nodes (RPELN) are included among the right central compartment lymph nodes (rCLN) and located behind right recurrent laryngeal nerve (rRLN). However, due to the likelihood of increasing postoperative complications, and the extremely difficulties of RPELN dissection, the decision to perform RPELN dissection remains controversial. The aim of this study was to explore the risk factors of RPELN metastasis and evaluate RPELN metastasis by preoperative examination. We reviewed the medical records of 163 consecutive papillary thyroid carcinoma (PTC) patients (125 females and 38 males) who underwent right lobe plus isthmic resection (91 patients) or total thyroidectomy (72 patients) with right or bilateral central compartment lymph node dissection. The RPELN dissections were performed in all patients and were individually dissected and recorded intraoperatively. All patients underwent thyroid ultrasound and enhanced neck computed tomography (CT) routinely during preoperative examination. RPELN metastasis was detected in 20 patients (12.3%), among whom 6 (3.7%) had RPELN metastasis without rCLN metastasis. Total rCLN metastasis and lateral compartment lymph node metastasis were confirmed in 57 (35.0%) and 24 (14.7%) patients, respectively. The tumour diameter, number of metastatic rCLN and lateral compartment lymph nodes, RPELN visible on CT, and enhanced CT value of RPELN were confirmed significantly associated with RPELN metastasis by univariate analysis (P < 0.05). The area under the ROC curve of CT values was 0.77 (95% CI, 0.59-0.95; P = 0.003). The CT value of 132.0 was used as the cut-off point, and the specificity and sensitivity were 84.1% and 71.4%, respectively. PTC patients with a large tumour (>1 cm) in the right lobe or suspected rCLN metastasis were recommended to undergo prophylactic RPELN dissection, particularly in those with a high enhanced CT value (>132) of RPELN or those with the copresence of lateral compartment lymph node metastasis. Copyright © 2017 IJS Publishing Group Ltd. Published by Elsevier Ltd. All rights reserved.

Effect of Axillary Dissection vs No Axillary Dissection on 10-Year Overall Survival Among Women With Invasive Breast Cancer and Sentinel Node Metastasis: The ACOSOG Z0011 (Alliance) Randomized Clinical Trial.

PubMed

Giuliano, Armando E; Ballman, Karla V; McCall, Linda; Beitsch, Peter D; Brennan, Meghan B; Kelemen, Pond R; Ollila, David W; Hansen, Nora M; Whitworth, Pat W; Blumencranz, Peter W; Leitch, A Marilyn; Saha, Sukamal; Hunt, Kelly K; Morrow, Monica

2017-09-12

The results of the American College of Surgeons Oncology Group Z0011 (ACOSOG Z0011) trial were first reported in 2005 with a median follow-up of 6.3 years. Longer follow-up was necessary because the majority of the patients had estrogen receptor-positive tumors that may recur later in the disease course (the ACOSOG is now part of the Alliance for Clinical Trials in Oncology). To determine whether the 10-year overall survival of patients with sentinel lymph node metastases treated with breast-conserving therapy and sentinel lymph node dissection (SLND) alone without axillary lymph node dissection (ALND) is noninferior to that of women treated with axillary dissection. The ACOSOG Z0011 phase 3 randomized clinical trial enrolled patients from May 1999 to December 2004 at 115 sites (both academic and community medical centers). The last date of follow-up was September 29, 2015, in the ACOSOG Z0011 (Alliance) trial. Eligible patients were women with clinical T1 or T2 invasive breast cancer, no palpable axillary adenopathy, and 1 or 2 sentinel lymph nodes containing metastases. All patients had planned lumpectomy, planned tangential whole-breast irradiation, and adjuvant systemic therapy. Third-field radiation was prohibited. The primary outcome was overall survival with a noninferiority hazard ratio (HR) margin of 1.3. The secondary outcome was disease-free survival. Among 891 women who were randomized (median age, 55 years), 856 (96%) completed the trial (446 in the SLND alone group and 445 in the ALND group). At a median follow-up of 9.3 years (interquartile range, 6.93-10.34 years), the 10-year overall survival was 86.3% in the SLND alone group and 83.6% in the ALND group (HR, 0.85 [1-sided 95% CI, 0-1.16]; noninferiority P = .02). The 10-year disease-free survival was 80.2% in the SLND alone group and 78.2% in the ALND group (HR, 0.85 [95% CI, 0.62-1.17]; P = .32). Between year 5 and year 10, 1 regional recurrence was seen in the SLND alone group vs none in the ALND group. Ten-year regional recurrence did not differ significantly between the 2 groups. Among women with T1 or T2 invasive primary breast cancer, no palpable axillary adenopathy, and 1 or 2 sentinel lymph nodes containing metastases, 10-year overall survival for patients treated with sentinel lymph node dissection alone was noninferior to overall survival for those treated with axillary lymph node dissection. These findings do not support routine use of axillary lymph node dissection in this patient population based on 10-year outcomes. clinicaltrials.gov Identifier: NCT00003855.

The learning curve of robot-assisted laparoscopic aortofemoral bypass grafting for aortoiliac occlusive disease.

PubMed

Novotný, Tomáš; Dvorák, Martin; Staffa, Robert

2011-02-01

Since the end of the 20th century, robot-assisted surgery has been finding its role among other minimally invasive methods. Vascular surgery seems to be another specialty in which the benefits of this technology can be expected. Our objective was to assess the learning curve of robot-assisted laparoscopic aortofemoral bypass grafting for aortoiliac occlusive disease in a group of 40 patients. Between May 2006 and January 2010, 40 patients (32 men, 8 women), who were a median age of 58 years (range, 48-75 years), underwent 40 robot-assisted laparoscopic aortofemoral reconstructions. Learning curve estimations were used for anastomosis, clamping, and operative time assessment. For conversion rate evaluation, the cumulative summation (CUSUM) technique was used. Statistical analysis comparing the first and second half of our group, and unilateral-to-bilateral reconstructions were performed. We created 21 aortofemoral and 19 aortobifemoral bypasses. The median proximal anastomosis time was 23 minutes (range, 18-50 minutes), median clamping time was 60 minutes (range, 40-95 minutes), and median operative time was 295 minutes (range, 180-475 minutes). The 30-day mortality rate was 0%, and no graft or wound infection or cardiopulmonary or hepatorenal complications were observed. During the median 18-month follow-up (range, 2-48 months), three early graft occlusions occurred (7%). After reoperations, the secondary patency of reconstructions was 100%. Data showed a typical short learning curve for robotic proximal anastomosis creation with anastomosis and clamping time reduction. The operative time learning curve was flat, confirming the procedure's complexity. There were two conversions to open surgery. CUSUM analysis confirmed that an acceptable conversion rate set at 5% was achieved. Comparing the first and second half of our group, all recorded times showed statistically significant improvements. Differences between unilateral and bilateral reconstructions were not statistically significant. Our results show that the success rate of robot-assisted laparoscopic aortofemoral bypass grafting is high and the complication rate is low. Anastomosis creation, one of the main difficulties of laparoscopic bypass grafting, has been overcome using the robotic operating system and its learning curve is short. However, the endoscopic dissection of the aortoiliac segment remains the most difficult part of the operation and should be addressed in further development of the method to reduce the operative times. Long-term results and potential benefits of this minimally invasive method have to be verified by randomized controlled clinical trials. Copyright © 2011 Society for Vascular Surgery. Published by Mosby, Inc. All rights reserved.

Comparison between wait-and-see policy and elective neck dissection in clinically N0 cutaneous squamous cell carcinoma of head and neck.

PubMed

Xiao, Yan; Yuan, Shuai; Liu, Fei; Liu, Bing; Zhu, Juanfang; He, Wei; Li, Wenlu; Kan, Quancheng

2018-06-01

To analyze the superiority of wait-and-see policy and elective neck dissection in treating cN0 patients with facial cutaneous cell carcinoma (cSCC).Patients with clinically negative parotid and neck metastasis disease were prospectively enrolled. Three groups were divided based on whether the patient received an operation of superficial parotidectomy or/and elective dissection, and regional control and disease-specific survival rates were compared.The occult parotid and neck metastasis rate was 20% and 16%, respectively. There was neck node metastasis without parotid metastasis in only 1 patient. All the node metastasis occurred in level II. Regional recurrence was noted in 16 (16%) patients, and 6 patients died of the disease. In the group undergoing superficial parotidectomy and elective neck dissection, 2 patients had neck node metastasis, and there was no disease-related death, further survival analysis indicated it had better regional control and disease-specific survival rates compared with the other 2 groups.Superficial parotidectomy and elective neck dissection are suggested for patients with T3-4 facial cutaneous squamous cell carcinoma.

Endometrial Cancer and the Role of Lymphadenectomy.

PubMed

Clark, Leslie H; Soper, John T

2016-06-01

The role of lymph node dissection in early-stage endometrial cancer is highly debated, but staging and prognosis are dependent on knowledge of lymph node metastasis. We sought to review the available data on the use of lymph node assessment in presumed early-stage endometrial cancer. A comprehensive literature review was performed using MEDLINE, the Cochrane Collaborative Database, and PubMed. There is limited retrospective data that suggest a therapeutic benefit to lymphadenectomy. Prospective randomized trials have not shown a benefit to lymphadenectomy in low-risk patients, but found significant morbidity in patients undergoing lymphadenectomy. Selective lymph node assessment should be used in low-risk endometrial cancer. Sentinel lymph node assessment is emerging as a potential strategy for lymph node assessment. Selective use of lymphadenectomy in early-stage endometrial cancer can reduce the morbidity associated with lymph node dissection without compromising clinical outcomes. Multiple strategies are available including sentinel lymph nodes and risk factor based lymphadenectomy.

How do I deal with the axilla in patients with a positive sentinel lymph node?

PubMed

Falkson, Conrad B

2011-12-01

Optimal management of the axilla in a patient with a positive sentinel node biopsy is not yet defined.These patients usually have Breast Conserving Surgery and receive adjuvant systemic therapy and whole breast radiation.Treatment options for the axilla include: no further surgery with or without radiation completion axillary nodal dissection with or without radiation Radiation options in addition to whole breast radiation include axillary and supraclavicular nodal irradiation regional nodal irradiationincludes supraclavicular and internal mammary nodes Completion axillary dissection has been standard practice in patients with positive sentinel nodes. the number of involved nodes provides prognostic information. theoretically improves local control, but may be obviated by systemic chemotherapy. but avoidance of dissection may not adversely affect locoregional control or survival. dissection has significant morbidity so safe avoidance is desirable. There is little worldwide concordance on the use of radiation: whole breast radiation (commonly used after breast conserving surgery) may radiate the lower axilla supraclavicular radiation is most commonly recommended for patients with four or more nodes but may confer a survival benefit on patients with lower risk disease. adding nodal irradiation reduces local recurrence with only modest toxicity. Adjuvant systemic therapy provides a survival benefit for patients with nodal disease. Most will receive cytostatic chemotherapy containing an anthracycline and a taxane. Hormone therapy is appropriate for estrogen receptor positive disease. The extent to which systemic therapy controls microscopic nodal disease is unknown. Node positive patients should generally receive adjuvant chemotherapy.A small group of patients benefit from specific nodal therapy. Further studies are needed to better identify these patients.

Quantitative photoacoustic assessment of ex-vivo lymph nodes of colorectal cancer patients

NASA Astrophysics Data System (ADS)

Sampathkumar, Ashwin; Mamou, Jonathan; Saegusa-Beercroft, Emi; Chitnis, Parag V.; Machi, Junji; Feleppa, Ernest J.

2015-03-01

Staging of cancers and selection of appropriate treatment requires histological examination of multiple dissected lymph nodes (LNs) per patient, so that a staggering number of nodes require histopathological examination, and the finite resources of pathology facilities create a severe processing bottleneck. Histologically examining the entire 3D volume of every dissected node is not feasible, and therefore, only the central region of each node is examined histologically, which results in severe sampling limitations. In this work, we assess the feasibility of using quantitative photoacoustics (QPA) to overcome the limitations imposed by current procedures and eliminate the resulting under sampling in node assessments. QPA is emerging as a new hybrid modality that assesses tissue properties and classifies tissue type based on multiple estimates derived from spectrum analysis of photoacoustic (PA) radiofrequency (RF) data and from statistical analysis of envelope-signal data derived from the RF signals. Our study seeks to use QPA to distinguish cancerous from non-cancerous regions of dissected LNs and hence serve as a reliable means of imaging and detecting small but clinically significant cancerous foci that would be missed by current methods. Dissected lymph nodes were placed in a water bath and PA signals were generated using a wavelength-tunable (680-950 nm) laser. A 26-MHz, f-2 transducer was used to sense the PA signals. We present an overview of our experimental setup; provide a statistical analysis of multi-wavelength classification parameters (mid-band fit, slope, intercept) obtained from the PA signal spectrum generated in the LNs; and compare QPA performance with our established quantitative ultrasound (QUS) techniques in distinguishing metastatic from non-cancerous tissue in dissected LNs. QPA-QUS methods offer a novel general means of tissue typing and evaluation in a broad range of disease-assessment applications, e.g., cardiac, intravascular, musculoskeletal, endocrine-gland, etc.

Mesothelioma With a Large Prevascular Lymph Node: N1 Involvement or Something Different?

PubMed

Berzenji, Lawek; Van Schil, Paul E; Snoeckx, Annemie; Hertoghs, Marjan; Carp, Laurens

2018-05-01

A 64-year-old man presented with a large amount of right-sided pleural fluid on imaging, together with calcified pleural plaques and an enlarged nodular structure in the prevascular mediastinum, presumably an enlarged lymph node. Pleural biopsies were obtained during video-assisted thoracoscopic surgery to exclude malignancy. Histopathology showed an epithelial malignant pleural mesothelioma. Induction chemotherapy with cisplatin and pemetrexed was administered followed by an extended pleurectomy and decortication with systematic nodal dissection. Histopathology confirmed the diagnosis of a ypT3N0M0 (stage IB) mesothelioma, and an unexpected thymoma type B2 (stage II) was discovered in the prevascular nodule. Simultaneous occurrence of a mesothelioma and thymoma is extremely rare. Copyright © 2018 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.

Analgesic Opioid Dose Is an Important Indicator of Postoperative Ileus Following Radical Cystectomy with Ileal Conduit: Experience in the Robotic Surgery Era

PubMed Central

Koo, Kyo Chul; Yoon, Young Eun; Chung, Byung Ha; Hong, Sung Joon

2014-01-01

Purpose Postoperative ileus (POI) is common following bowel resection for radical cystectomy with ileal conduit (RCIC). We investigated perioperative factors associated with prolonged POI following RCIC, with specific focus on opioid-based analgesic dosage. Materials and Methods From March 2007 to January 2013, 78 open RCICs and 26 robot-assisted RCICs performed for bladder carcinoma were identified with adjustment for age, gender, American Society of Anesthesiologists grade, and body mass index (BMI). Perioperative records including operative time, intraoperative fluid excess, estimated blood loss, lymph node yield, and opioid analgesic dose were obtained to assess their associations with time to passage of flatus, tolerable oral diet, and length of hospital stay (LOS). Prior to general anaesthesia, patients received epidural patient-controlled analgesia (PCA) consisted of fentanyl with its dose adjusted for BMI. Postoperatively, single intravenous injections of tramadol were applied according to patient desire. Results Multivariate analyses revealed cumulative dosages of both PCA fentanyl and tramadol injections as independent predictors of POI. According to surgical modality, linear regression analyses revealed cumulative dosages of PCA fentanyl and tramadol injections to be positively associated with time to first passage of flatus, tolerable diet, and LOS in the open RCIC group. In the robot-assisted RCIC group, only tramadol dose was associated with time to flatus and tolerable diet. Compared to open RCIC, robot-assisted RCIC yielded shorter days to diet and LOS; however, it failed to shorten days to first flatus. Conclusion Reducing opioid-based analgesics shortens the duration of POI. The utilization of the robotic system may confer additional benefit. PMID:25048497

Significance of prophylactic modified radical neck dissection for patients with low-risk papillary thyroid carcinoma measuring 1.1-3.0 cm: first report of a trial at Kuma Hospital.

PubMed

Ito, Yasuhiro; Tsushima, Yukiko; Masuoka, Hiroo; Yabuta, Tomonori; Fukushima, Mitsuhiro; Inoue, Hiroyuki; Tomoda, Chisato; Kihara, Minoru; Higashiyama, Takuya; Takamura, Yuuki; Kobayashi, Kaoru; Miya, Akihiro; Miyauchi, Akira

2011-11-01

Papillary thyroid carcinoma (PTC) frequently metastasizes to and recurs in regional lymph nodes. Of the two compartments, the central compartment can be dissected through the same wound as the thyroidectomy, and the central node dissection (CND) is routinely performed in most Japanese surgical departments. However, the indications for prophylactic lateral compartment dissection (modified radical neck dissection [MND]) for low-risk PTC remain unclear. In this study, we investigated the indications for prophylactic MND for PTC patients with tumor measuring 1.1-3.0 cm without significant extrathyroid extension or distant metastasis. We investigated the lymph node disease-free survival (LN-DFS) rates of 829 patients who underwent CND and of 414 patients who underwent MND and CND between 2005 and 2007 at Kuma Hospital. The LN-DFS of these two groups was not significantly different. In the subset of patients with CND only, clinical central node metastasis (N1a) significantly predicted a worse LN-DFS. All N1a patients recognized as showing recurrence developed such recurrence in the lateral compartment. Other conventional prognostic factors, such as sex and age, were not related to LN-DFS. Taken together, N1a patients with low-risk PTC measuring 1.1-3.0 cm can be considered as candidates for prophylactic MND.

Development and Validation of a Quality Assurance Score for Robot-assisted Radical Cystectomy: A 10-year Analysis.

PubMed

Hussein, Ahmed A; Dibaj, Shiva; Hinata, Nobuyuki; Field, Erinn; O'leary, Kathleen; Kuvshinoff, Boris; Mohler, James L; Wilding, Gregory; Guru, Khurshid A

2016-11-01

To develop quality assessment tool to evaluate surgical performance for robot-assisted radical cystectomy program. A prospectively maintained quality assurance database of 425 consecutive robot-assisted radical cystectomies performed by a single surgeon between 2005 and 2015 was retrospectively reviewed. Potentially modifiable factors, related to the management and perioperative care of patients, were used to evaluate patient care. Criteria included the following: preoperative (administration of neoadjuvant chemotherapy); operative (operative time <6.5 hours and estimated blood loss <500 cc); pathologic (negative soft tissue surgical margins and lymph node yield ≥20); and postoperative (no high-grade complications, readmission, or noncancer-related mortality within 30 days).The Quality Cystectomy Score (QCS) was developed (1 star: achieving ≤2 criteria or mortality within 30 days; 2 stars: 3 or 4 criteria met; 3 stars: 5 or 6 criteria met; and 4 stars: 7 or all criteria met). Univariate and multivariate Cox proportional hazard regression models were fitted to test for the association between QCS and survival outcomes. Most patients (85%) achieved at least 3 stars, and more patients achieved 4 stars with time. High QCS was associated with better recurrence-free, cancer-specific, and overall survival (P values <.05). None of the patients with 1-star were alive at 1 year. Patients with 4 stars achieved the best survival rates (recurrence-free survival [62%], cancer-specific survival [70%], and overall survival [53%] at 5 years) (log rank P < .0001). Continuous assessment for quality improvement facilitated implementation and maintenance of robot-assisted program for bladder cancer. Copyright © 2016 Elsevier Inc. All rights reserved.

Standardized analysis of frequency and severity of complications after robot-assisted radical cystectomy.

PubMed

Yuh, Bertram E; Nazmy, Michael; Ruel, Nora H; Jankowski, Jason T; Menchaca, Anita R; Torrey, Robert R; Linehan, Jennifer A; Lau, Clayton S; Chan, Kevin G; Wilson, Timothy G

2012-11-01

Comprehensive and standardized reporting of adverse events after robot-assisted radical cystectomy (RARC) and urinary diversion for bladder cancer is necessary to evaluate the magnitude of morbidity for this complex operation. To accurately identify and assess postoperative morbidity after RARC using a standardized reporting system. A total of 241 consecutive patients underwent RARC, extended pelvic lymph node dissection, and urinary diversion between 2003 and 2011. In all, 196 patients consented to a prospective database, and they are the subject of this report. Continent diversions were performed in 68% of cases. All complications within 90 d of surgery were defined and categorized by a five-grade and 10-domain modification of the Clavien system. Univariable and multivariable logistic regression analyses were used to identify predictors of complications. Grade 1-2 complications were categorized as minor, and grade 3-5 complications were categorized as major. All blood transfusions were recorded as grade ≥2. Eighty percent of patients (156 of 196 patients) experienced a complication of any grade ≤90 d after surgery. A total of 475 adverse events (113 major) were recorded, with 365 adverse events (77%) occurring ≤30 d after surgery. Sixty-eight patients (35%) experienced a major complication within the first 90 d. Other than blood transfusions given (86 patients [43.9%]), infectious, gastrointestinal, and procedural complications were the most common, at 16.2%, 14.1%, and 10.3%, respectively. Age, comorbidity, preoperative hematocrit, estimated blood loss, and length of surgery were predictive of a complication of any grade, while comorbidity, preoperative hematocrit, and orthotopic diversion were predictive of major complications. The 90-d mortality rate was 4.1%. The main limitation is lack of a control group. Analysis of postoperative morbidity following RARC demonstrates a considerable complication rate, though the rate is comparable to contemporary open series that followed similar reporting guidelines. This finding reinforces the need for complete and standardized reporting when evaluating surgical techniques and comparing published series. Copyright © 2012 European Association of Urology. Published by Elsevier B.V. All rights reserved.

Robotic Cholecystectomy Using the Newly Developed Korean Robotic Surgical System, Revo-i: A Preclinical Experiment in a Porcine Model.

PubMed

Kang, Chang Moo; Chong, Jae Uk; Lim, Jin Hong; Park, Dong Won; Park, Sung Jun; Gim, Suhyeon; Ye, Hye Jin; Kim, Se Hoon; Lee, Woo Jung

2017-09-01

One Korean company recently successfully produced a robotic surgical system prototype called Revo-i (MSR-5000). We, therefore, conducted a preclinical study for robotic cholecystectomy using Revo-i, and this is a report of the first case of robotic cholecystectomy performed using the Revo-i system in a preclinical porcine model. Revo-i consists of a surgeon console (MSRC-5000), operation cart (MSRO-5000) and vision cart (MSRV-5000), and a 40 kg-healthy female porcine was prepared for robotic cholecystectomy with general anesthesia. The primary end point was the safe completion of these procedures using Revo-i: The total operation time was 88 minutes. The dissection time was defined as the time from the initial dissection of the Calot area to the time to complete gallbladder detachment from the liver bed: The dissection time required 14 minutes. The surgical console time was 45 minutes. There was no gallbladder perforation or significant bleeding noted during the procedure. The porcine survived for two weeks postoperatively without any complications. Like the da Vinci surgical system, the Revo-i provides a three-dimensional operative view and allows for angulated instrument motion (forceps, needle-holders, clip-appliers, scissors, bipolar energy, and hook monopolar energy), facilitating an effective laparoscopic procedure. Our experience suggests that robotic cholecystectomy can be safely completed in a porcine model using Revo-i. © Copyright: Yonsei University College of Medicine 2017.

[Pay attention to the selective lateral pelvic lymph node dissection in mid-low rectal cancer].

PubMed

Meng, Wenjian; Wang, Ziqiang

2017-03-25

Lateral pelvic lymph node metastasis is an important metastatic mode and a major cause of locoregional recurrence of mid-low rectal cancer. Recently, there is an East-West discrepancy in regard to the diagnosis, clinical significance, treatment and prognosis of lateral pelvic lymph node metastasis. In the West, lateral nodal involvement may represent systemic disease and preoperative chemoradiotherapy can sterilize clinically suspected lateral nodes. Thus, in many Western countries, the standard therapy for lower rectal cancer is total mesorectal excision with chemoradiotherapy, and pelvic sidewall dissection is rarely performed. In the East, and Japan in particular, however, there is a positive attitude in regard to lateral pelvic lymph node dissection (LPND). They consider that lateral pelvic lymph node metastasis is as regional metastasis, and the clinically suspected lateral nodes can not be removed by neoadjuvant chemoradiotherapy. The selective LPND after neoadjuvant chemoradiotherapy may be found to be promising treatment for the improvement of therapeutic benefits in these patients. Therefore, the large-scale prospective studies are urgently required to improve selection criteria for LPND and neoadjuvant treatment to prevent overtreatment in the near future. Selective LPND after neoadjuvant treatment based on modern imaging techniques is expected to reduce locoregional recurrence and improve long-term survival in patients with mid-low rectal cancer.

Current advances in diagnosis and surgical treatment of lymph node metastasis in head and neck cancer

PubMed Central

Teymoortash, A.; Werner, J. A.

2012-01-01

Still today, the status of the cervical lymph nodes is the most important prognostic factor for head and neck cancer. So the individual treatment concept of the lymphatic drainage depends on the treatment of the primary tumor as well as on the presence or absence of suspect lymph nodes in the imaging diagnosis. Neck dissection may have either a therapeutic objective or a diagnostic one. The selective neck dissection is currently the method of choice for the treatment of patients with advanced head and neck cancers and clinical N0 neck. For oncologic reasons, this procedure is generally recommended with acceptable functional and aesthetic results, especially under the aspect of the mentioned staging procedure. In this review article, current aspects on pre- and posttherapeutic staging of the cervical lymph nodes are described and the indication and the necessary extent of neck dissection for head and neck cancer is discussed. Additionally the critical question is discussed if the lymph node metastasis bears an intrinsic risk of metastatic development and thus its removal in a most possible early stage plays an important role. PMID:23320056

A Specific Mapping Study Using Fluorescence Sentinel Lymph Node Detection in Patients with Intermediate- and High-risk Prostate Cancer Undergoing Extended Pelvic Lymph Node Dissection.

PubMed

Nguyen, Daniel P; Huber, Philipp M; Metzger, Tobias A; Genitsch, Vera; Schudel, Hans H; Thalmann, George N

2016-11-01

Sentinel lymph node (SLN) detection techniques have the potential to change the standard of surgical care for patients with prostate cancer. We performed a lymphatic mapping study and determined the value of fluorescence SLN detection with indocyanine green (ICG) for the detection of lymph node metastases in intermediate- and high-risk patients undergoing radical prostatectomy and extended pelvic lymph node dissection. A total of 42 patients received systematic or specific ICG injections into the prostate base, the midportion, the apex, the left lobe, or the right lobe. We found (1) that external and internal iliac regions encompass the majority of SLNs, (2) that common iliac regions contain up to 22% of all SLNs, (3) that a prostatic lobe can drain into the contralateral group of pelvic lymph nodes, and (4) that the fossa of Marcille also receives significant drainage. Among the 12 patients who received systematic ICG injections, 5 (42%) had a total of 29 lymph node metastases. Of these, 16 nodes were ICG positive, yielding 55% sensitivity. The complex drainage pattern of the prostate and the low sensitivity of ICG for the detection of lymph node metastases reported in our study highlight the difficulties related to the implementation of SNL techniques in prostate cancer. There is controversy about how extensive lymph node dissection (LND) should be during prostatectomy. We investigated the lymphatic drainage of the prostate and whether sentinel node fluorescence techniques would be useful to detect node metastases. We found that the drainage pattern is complex and that the sentinel node technique is not able to replace extended pelvic LND. Copyright © 2016. Published by Elsevier B.V.

Lymph node pick up by separate stations: Option or necessity.

PubMed

Morgagni, Paolo; Nanni, Oriana; Carretta, Elisa; Altini, Mattia; Saragoni, Luca; Falcini, Fabio; Garcea, Domenico

2015-05-27

To evaluate whether lymph node pick up by separate stations could be an indicator of patients submitted to appropriate surgical treatment. One thousand two hundred and three consecutive gastric cancer patients submitted to radical resection in 7 general hospitals and for whom no information was available on the extension of lymphatic dissection were included in this retrospective study. Patients were divided into 2 groups: group A, where the stomach specimen was directly formalin-fixed and sent to the pathologist, and group B, where lymph nodes were picked up after surgery and fixed for separate stations. Sixty-two point three percent of group A patients showed < 16 retrieved lymph nodes compared to 19.4% of group B (P < 0.0001). Group B (separate stations) patients had significantly higher survival rates than those in group A [46.1 mo (95%CI: 36.5-56.0) vs 27.7 mo (95%CI: 21.3-31.9); P = 0.0001], independently of T or N stage. In multivariate analysis, group A also showed a higher risk of death than group B (HR = 1.24; 95%CI: 1.05-1.46). Separate lymphatic station dissection increases the number of retrieved nodes, leads to better tumor staging, and permits verification of the surgical dissection. The number of dissected stations could potentially be used as an index to evaluate the quality of treatment received.

Review of the role of sentinel node biopsy in cutaneous head and neck melanoma.

PubMed

Roy, Jennifer M; Whitfield, Robert J; Gill, P Grantley

2016-05-01

Sentinel node biopsy (SNB) is recommended for selected melanoma patients in many parts of the world. This review examines the evidence surrounding the accuracy and prognostic value of SNB and completion neck dissection in head and neck melanoma. Sentinel nodes were identified in an average of 94.7% of head and neck cases compared with 95.3-100% in all melanoma cases. More false-negative sentinel nodes were found in head and neck cases. A positive sentinel node was associated with both lower disease-free survival (53.4 versus 83.2%) and overall survival (40 versus 84%). We conclude that SNB should be offered to all patients with intermediate and high-risk melanomas in the head and neck area. To date, evidence does not exist to demonstrate the safety of avoiding completion lymph node dissection in sentinel node-positive patients with head and neck melanoma. © 2015 Royal Australasian College of Surgeons.

Quantification of loading in biomechanical testing: the influence of dissection sequence.

PubMed

Funabashi, Martha; El-Rich, Marwan; Prasad, Narasimha; Kawchuk, Gregory N

2015-09-18

Sequential dissection is a technique used to investigate loads experienced by articular tissues. When the joint of interest is tested in an unconstrained manner, its kinematics change with each tissue removal. To address this limitation, sufficiently rigid robots are used to constrain joint kinematics. While this approach can quantify loads experienced by each tissue, it does not assure similar results when removal order is changed. Specifically, structure loading is assumed to be independent of removal order if the structure behaves linearly (i.e. principle of superposition applies), but dependent on removal order when response is affected by material and/or geometry nonlinearities and/or viscoelasticiy (e.g. biological tissues). Therefore, this experiment was conducted to evaluate if structure loading created through robotic testing is dependent on the order in which connectors are removed. Six identical models were 3D printed. Each model was composed of 2 rigid bodies and 3 connecting structures with nonlinear time-dependent behavior. To these models, pure rotations were applied about a predefined static center of rotation using a parallel robot. A unique dissection sequence was used for each of the six models and the same movements applied robotically after each dissection. When comparing the moments experienced by each structure between different removal sequences, a statistically significant difference (p<0.05) was observed. These results suggest that even in an optimized environment, the sequence in which nonlinear viscoelastic structures are removed influence model loading. These findings support prior work suggesting that tissue loads obtained from robotic testing are specific to removal order. Copyright © 2015 Elsevier Ltd. All rights reserved.

Transoral robotic thyroidectomy: a preclinical feasibility study using the da Vinci Xi platform.

PubMed

Russell, Jonathon O; Noureldine, Salem I; Al Khadem, Mai G; Chaudhary, Hamad A; Day, Andrew T; Kim, Hoon Yub; Tufano, Ralph P; Richmon, Jeremy D

2017-09-01

Transoral thyroid surgery allows the surgeon to conceal incisions within the oral cavity without significantly increasing the amount of required dissection. TORT provides an ideal scarless, midline access to the thyroid gland and bilateral central neck compartments. This approach, however, presents multiple technical challenges. Herein, we present our experience using the latest generation robotic surgical system to accomplish transoral robotic thyroidectomy (TORT). In two human cadavers, the da Vinci Xi surgical system (Intuitive Surgical, Sunnyvale, CA, USA) was used to complete TORT. Total thyroidectomy and bilateral central neck dissection was successfully completed in both cadavers. The da Vinci Xi platform offered several technologic advantages over previous robotic generations including overhead docking, narrower arms, and improved range of motion allowing for improved execution of previously described TORT techniques.

Towards cybernetic surgery: robotic and augmented reality-assisted liver segmentectomy.

PubMed

Pessaux, Patrick; Diana, Michele; Soler, Luc; Piardi, Tullio; Mutter, Didier; Marescaux, Jacques

2015-04-01

Augmented reality (AR) in surgery consists in the fusion of synthetic computer-generated images (3D virtual model) obtained from medical imaging preoperative workup and real-time patient images in order to visualize unapparent anatomical details. The 3D model could be used for a preoperative planning of the procedure. The potential of AR navigation as a tool to improve safety of the surgical dissection is outlined for robotic hepatectomy. Three patients underwent a fully robotic and AR-assisted hepatic segmentectomy. The 3D virtual anatomical model was obtained using a thoracoabdominal CT scan with a customary software (VR-RENDER®, IRCAD). The model was then processed using a VR-RENDER® plug-in application, the Virtual Surgical Planning (VSP®, IRCAD), to delineate surgical resection planes including the elective ligature of vascular structures. Deformations associated with pneumoperitoneum were also simulated. The virtual model was superimposed to the operative field. A computer scientist manually registered virtual and real images using a video mixer (MX 70; Panasonic, Secaucus, NJ) in real time. Two totally robotic AR segmentectomy V and one segmentectomy VI were performed. AR allowed for the precise and safe recognition of all major vascular structures during the procedure. Total time required to obtain AR was 8 min (range 6-10 min). Each registration (alignment of the vascular anatomy) required a few seconds. Hepatic pedicle clamping was never performed. At the end of the procedure, the remnant liver was correctly vascularized. Resection margins were negative in all cases. The postoperative period was uneventful without perioperative transfusion. AR is a valuable navigation tool which may enhance the ability to achieve safe surgical resection during robotic hepatectomy.

Sentinel lymph node dissection only versus complete axillary lymph node dissection in early invasive breast cancer: a systematic review and meta-analysis.

PubMed

Glechner, Anna; Wöckel, Achim; Gartlehner, Gerald; Thaler, Kylie; Strobelberger, Michaela; Griebler, Ursula; Kreienberg, Rolf

2013-03-01

The Z0011-study, a landmark randomised controlled trial (RCT) challenged the benefits of complete axillary lymph node dissection (ALND) compared with sentinel lymph node dissection only (SLND) in breast cancer patients with positive sentinel nodes. The study, however, has been criticised for lack of power and low applicability. The aim of this review was to systematically assess the evidence on the comparative benefits and harms of ALND versus SLND for sentinel node positive breast cancer patients. We systematically searched PubMed, Embase, the Cochrane Library, and reference lists of pertinent review articles from January 2006 to August 2011. We dually reviewed the literature and rated the risk of bias of each study. For effectiveness, we included RCTs and observational studies of at least 1 year follow-up. In addition, we considered studies conducted in sentinel node-negative women to assess the risk of harms. If data were sufficient, we conducted random effects meta-analysis of outcomes of interest. Meta-analysis of three studies with 50,120 patients indicated similar 5-year survival and regional recurrence rates between patients treated with ALND or SLND, although prognostic tumour characteristics varied among the 3 study-populations. Results from 6 studies on more than 11,500 patients reported a higher risk for harms for ALND than SLND. Long-term evidence on pertinent health outcomes is missing. The available evidence indicates that for some women with early invasive breast cancer SLND appears to be a justifiable alternative to ALND. Surgeons need to discuss advantages and disadvantages of both approaches with their patients. Copyright © 2012 Elsevier Ltd. All rights reserved.

The Impact of Implementation of the European Association of Urology Guidelines Panel Recommendations on Reporting and Grading Complications on Perioperative Outcomes after Robot-assisted Radical Prostatectomy.

PubMed

Gandaglia, Giorgio; Bravi, Carlo Andrea; Dell'Oglio, Paolo; Mazzone, Elio; Fossati, Nicola; Scuderi, Simone; Robesti, Daniele; Barletta, Francesco; Grillo, Luca; Maclennan, Steven; N'Dow, James; Montorsi, Francesco; Briganti, Alberto

2018-03-12

The rate of postoperative complications might vary according to the method used to collect perioperative data. We aimed at assessing the impact of the prospective implementation of the European Association of Urology (EAU) guidelines on reporting and grading of complications in prostate cancer patients undergoing robot-assisted radical prostatectomy (RARP). From September 2016, an integrated method for reporting surgical morbidity based on the EAU guidelines was implemented at a single, tertiary center. Perioperative data were prospectively and systematically collected during a patient interview at 30 d after surgery as recommended by the EAU Guidelines Panel Recommendations on Reporting and Grading Complications. The rate and grading of complications of 167 patients who underwent RARP±pelvic lymph node dissection (PLND) after the implementation of the prospective collection system (Group 1) were compared with 316 patients treated between January 2015 and August 2016 (Group 2) when a system based on patient chart review was used. No differences were observed in disease characteristics and PLND between the two groups (all p≥0.1). Postoperative complications were graded according to the Clavien-Dindo classification system. Overall, the complication rate was higher when the prospective collection system based on the EAU guidelines was used (29%) than when retrospective chart review (10%; p<0.001) was used. In particular, a substantially higher rate of grade 1 (8.4% vs 4.7%) and 2 (14% vs 2.8%) complications was detected in Group 1 versus Group 2 (p<0.001). Although the rate of complications occurred during hospitalization did not differ (13% vs 10%; p=0.3), 31 (19%) complications after discharge were detected in Group 1. This resulted into a readmission rate of 16%. Conversely, no complications after discharge and readmissions were recorded for Group 2. The implementation of the EAU guidelines on reporting perioperative outcomes roughly doubled the complication rate after RARP and allowed for the detection of complications after discharge in more than 15% of patients that would have been otherwise missed, where patients assessed with the EAU implemented protocol had a threefold higher likelihood of reporting complications. The implementation of the European Association of Urology guidelines on reporting and grading of complications after urologic procedures in prostate cancer patients roughly doubled the complication rate after robot-assisted radical prostatectomy compared to retrospective patient chart review. Moreover, it allowed for the detection of complications after discharge in more than 15% of patients that would have been otherwise missed. Copyright © 2018 European Association of Urology. Published by Elsevier B.V. All rights reserved.

Robotic surgery in supermorbidly obese patients with endometrial cancer.

PubMed

Stephan, Jean-Marie; Goodheart, Michael J; McDonald, Megan; Hansen, Jean; Reyes, Henry D; Button, Anna; Bender, David

2015-07-01

Morbid obesity is a known risk factor for the development of endometrial cancer. Several studies have demonstrated the overall feasibility of robotic-assisted surgical staging for endometrial cancer as well as the benefits of robotics compared with laparotomy. However, there have been few reports that have evaluated robotic surgery for endometrial cancer in the supermorbidly obese population (body mass index [BMI], ≥50 kg/m(2)). We sought to evaluate safety, feasibility, and outcomes for supermorbidly obese patients who undergo robotic surgery for endometrial cancer, compared with patients with lower body mass indices. We performed a retrospective chart review of 168 patients with suspected early-stage endometrial adenocarcinoma who underwent robotic surgery for the management of their disease. Analysis of variance and univariate logistic regression were used to compare patient characteristics and surgical variables across all body weights. Cox proportional hazard regression was used to determine the impact of body weight on recurrence-free and overall survival. The mean BMI of our cohort was 40.9 kg/m(2). Median follow up was 31 months. Fifty-six patients, 30% of which had grade 2 or 3 tumors, were supermorbidly obese with a BMI of ≥50 kg/m(2) (mean, 56.3 kg/m(2)). A comparison between the supermorbidly obese and lower-weight patients demonstrated no differences in terms of length of hospital stay, blood loss, complication rates, numbers of pelvic and paraaortic lymph nodes retrieved, or recurrence and survival. There was a correlation between BMI and conversion to an open procedure, in which the odds of conversion increased with increasing BMI (P = .02). Offering robotic surgery to supermorbidly obese patients with endometrial cancer is a safe and feasible surgical management option. When compared with patients with a lower BMI, the supermorbidly obese patient had a similar outcome, length of hospital stay, blood loss, complications, and numbers of lymph nodes retrieved. Copyright © 2015 Elsevier Inc. All rights reserved.

A Multimodal Adaptive Wireless Control Interface for People With Upper-Body Disabilities.

PubMed

Fall, Cheikh Latyr; Quevillon, Francis; Blouin, Martine; Latour, Simon; Campeau-Lecours, Alexandre; Gosselin, Clement; Gosselin, Benoit

2018-06-01

This paper describes a multimodal body-machine interface (BoMI) to help individuals with upper-limb disabilities using advanced assistive technologies, such as robotic arms. The proposed system uses a wearable and wireless body sensor network (WBSN) supporting up to six sensor nodes to measure the natural upper-body gesture of the users and translate it into control commands. Natural gesture of the head and upper-body parts, as well as muscular activity, are measured using inertial measurement units (IMUs) and surface electromyography (sEMG) using custom-designed multimodal wireless sensor nodes. An IMU sensing node is attached to a headset worn by the user. It has a size of 2.9 cm 2.9 cm, a maximum power consumption of 31 mW, and provides angular precision of 1. Multimodal patch sensor nodes, including both IMU and sEMG sensing modalities are placed over the user able-body parts to measure the motion and muscular activity. These nodes have a size of 2.5 cm 4.0 cm and a maximum power consumption of 11 mW. The proposed BoMI runs on a Raspberry Pi. It can adapt to several types of users through different control scenarios using the head and shoulder motion, as well as muscular activity, and provides a power autonomy of up to 24 h. JACO, a 6-DoF assistive robotic arm, is used as a testbed to evaluate the performance of the proposed BoMI. Ten able-bodied subjects performed ADLs while operating the AT device, using the Test d'Évaluation des Membres Supérieurs de Personnes Âgées to evaluate and compare the proposed BoMI with the conventional joystick controller. It is shown that the users can perform all tasks with the proposed BoMI, almost as fast as with the joystick controller, with only 30% time overhead on average, while being potentially more accessible to the upper-body disabled who cannot use the conventional joystick controller. Tests show that control performance with the proposed BoMI improved by up to 17% on average, after three trials.

DO PROXIMAL AND DISTAL GASTRIC TUMOURS BEHAVE DIFFERENTLY?

PubMed Central

da COSTA, Laurence Bedin; TONETO, Marcelo Garcia; MOREIRA, Luis Fernando

2016-01-01

ABSTRACT Background: Although the incidence of gastric (adenocarcinoma) cancer has been decreasing over time, it is still one of the most common malignancies worldwide, and proximal tumours tend to have a worse prognosis. Aim: To compare surgical outcomes and prognosis between proximal - excluding tumours of the cardia - and distal gastric cancer. Methods: Out of 293 cases reviewed - 209 with distal and 69 with proximal gastric cancer - were compared for clinical and pathological features, stage, surgical outcome, mortality and survival. Results: Statistically, there was no significant difference between patients in both groups regarding mortality (p=0.661), adjuvant chemotherapy (p 0.661), and radiation (p=1.000). However, there was significant difference in the degree of lymph node dissection employed (p=0.002) and the number of positive lymph nodes resected (p=0.038) between the two groups. The odds of death at five years for patients who had a D0 dissection was three times greater (odds ratio 2.78; (95%CI 1.33-5.82) than that for patients who had a D2 dissection, while for patients who had a D1 dissection the odds ratio was only 1.41 (95%CI 0.71-2.83) compared to D2-dissected patients. Conclusion: Although no significant differences were found between proximal and distal gastric cancer, the increased risk of death in D0- and D1-dissected patients clearly suggests an important role of radical D2 lymph node dissection in survival. PMID:28076476

Endometrial cancer - reduce to the minimum. A new paradigm for adjuvant treatments?

PubMed Central

2011-01-01

Background Up to now, the role of adjuvant radiation therapy and the extent of lymph node dissection for early stage endometrial cancer are controversial. In order to clarify the current position of the given adjuvant treatment options, a systematic review was performed. Materials and methods Both, Pubmed and ISI Web of Knowledge database were searched using the following keywords and MESH headings: "Endometrial cancer", "Endometrial Neoplasms", "Endometrial Neoplasms/radiotherapy", "External beam radiation therapy", "Brachytherapy" and adequate combinations. Conclusion Recent data from randomized trials indicate that external beam radiation therapy - particularly in combination with extended lymph node dissection - or radical lymph node dissection increases toxicity without any improvement of overall survival rates. Thus, reduced surgical aggressiveness and limitation of radiotherapy to vaginal-vault-brachytherapy only is sufficient for most cases of early stage endometrial cancer. PMID:22118369

Management of chyle leakage after thyroidectomy, cervical lymph node dissection, in patients with thyroid cancer.

PubMed

Park, Inhye; Her, Nayoon; Choe, Jun-Ho; Kim, Jee Soo; Kim, Jung-Han

2018-01-01

The purpose of this study was to evaluate the incidence and pattern of chyle leakage after thyroidectomy and/or cervical lymph node dissection and to establish management protocols for chyle leakage. Patients who underwent surgical management for thyroid cancer were analyzed retrospectively. For this study, 131 patients with chyle leakage were identified; the overall incidence was 0.9%. Of them, 43.7% of patients underwent central neck dissection without lateral neck dissection, and chyle leakage was easily controlled with conservative management. Patients whose chyle drainage was reduced by >50% after dietary modification had a significantly shorter hospital stay (P < .001); NPO was the most effective dietary modification. The occurrence of chyle leakage after central compartment dissection even without lateral neck dissection was not rare, but was easily controlled with conservative management. Surgical management should be considered if the drainage amount does not decrease by >50% of the original amount of the day of detection after 2 days of NPO. © 2017 Wiley Periodicals, Inc.

Automatic planning of needle placement for robot-assisted percutaneous procedures.

PubMed

Belbachir, Esia; Golkar, Ehsan; Bayle, Bernard; Essert, Caroline

2018-04-18

Percutaneous procedures allow interventional radiologists to perform diagnoses or treatments guided by an imaging device, typically a computed tomography (CT) scanner with a high spatial resolution. To reduce exposure to radiations and improve accuracy, robotic assistance to needle insertion is considered in the case of X-ray guided procedures. We introduce a planning algorithm that computes a needle placement compatible with both the patient's anatomy and the accessibility of the robot within the scanner gantry. Our preoperative planning approach is based on inverse kinematics, fast collision detection, and bidirectional rapidly exploring random trees coupled with an efficient strategy of node addition. The algorithm computes the allowed needle entry zones over the patient's skin (accessibility map) from 3D models of the patient's anatomy, the environment (CT, bed), and the robot. The result includes the admissible robot joint path to target the prescribed internal point, through the entry point. A retrospective study was performed on 16 patients datasets in different conditions: without robot (WR) and with the robot on the left or the right side of the bed (RL/RR). We provide an accessibility map ensuring a collision-free path of the robot and allowing for a needle placement compatible with the patient's anatomy. The result is obtained in an average time of about 1 min, even in difficult cases. The accessibility maps of RL and RR covered about a half of the surface of WR map in average, which offers a variety of options to insert the needle with the robot. We also measured the average distance between the needle and major obstacles such as the vessels and found that RL and RR produced needle placements almost as safe as WR. The introduced planning method helped us prove that it is possible to use such a "general purpose" redundant manipulator equipped with a dedicated tool to perform percutaneous interventions in cluttered spaces like a CT gantry.

Adenocarcinoma arising at a colostomy site with inguinal lymph node metastasis: report of a case.

PubMed

Iwamoto, Masayoshi; Kawada, Kenji; Hida, Koya; Hasegawa, Suguru; Sakai, Yoshiharu

2015-02-01

Inguinal lymph node metastasis from adenocarcinoma arising at a colostomy site is extremely rare, and the significance of surgical resection for metastatic inguinal lymph nodes has not been established. An 82-year-old woman who had undergone abdominoperineal resection 27 years earlier was admitted to our hospital complaining of bleeding from a colostomy. Physical examination revealed that a tumor at the colostomy site directly invaded into the peristomal skin, and that a left inguinal lymph node was firm and swollen. Positron emission tomography/computed tomography scan demonstrated accumulation of (18)F-fluorodeoxy glucose into both the colostomy tumor and the left swollen inguinal lymph node, while there was no evidence of metastasis to liver or lungs. She underwent open left hemicolectomy with wide local resection of the colostomy, and dissection of left inguinal lymph nodes. Histological diagnosis was a moderately differentiated adenocarcinoma that directly invaded into the surrounding skin and metastasized to the left inguinal lymph node. The patient has been followed up for >5 years without any sign of recurrence. In general, inguinal lymph node metastasis from colorectal cancers is regarded as a systemic disease with a poor prognosis, and so systemic chemotherapy and radiotherapy, but not surgical lymph node dissection, are recommended. Considering the lymphatic drainage route in the present case, inguinal lymph node metastasis does not represent a systemic disease but rather a sentinel nodal metastasis from adenocarcinoma at a colostomy site. Surgical dissection of metastatic inguinal lymph nodes should be considered to enable a favorable prognosis in the absence of distant metastasis to other organs. © The Author 2014. Published by Oxford University Press. All rights reserved. For Permissions, please email: journals.permissions@oup.com.

Crowdsourcing Assessment of Surgeon Dissection of Renal Artery and Vein During Robotic Partial Nephrectomy: A Novel Approach for Quantitative Assessment of Surgical Performance.

PubMed

Powers, Mary K; Boonjindasup, Aaron; Pinsky, Michael; Dorsey, Philip; Maddox, Michael; Su, Li-Ming; Gettman, Matthew; Sundaram, Chandru P; Castle, Erik P; Lee, Jason Y; Lee, Benjamin R

2016-04-01

We sought to describe a methodology of crowdsourcing for obtaining quantitative performance ratings of surgeons performing renal artery and vein dissection of robotic partial nephrectomy (RPN). We sought to compare assessment of technical performance obtained from the crowdsourcers with that of surgical content experts (CE). Our hypothesis is that the crowd can score performances of renal hilar dissection comparably to surgical CE using the Global Evaluative Assessment of Robotic Skills (GEARS). A group of resident and attending robotic surgeons submitted a total of 14 video clips of RPN during hilar dissection. These videos were rated by both crowd and CE for technical skills performance using GEARS. A minimum of 3 CE and 30 Amazon Mechanical Turk crowdworkers evaluated each video with the GEARS scale. Within 13 days, we received ratings of all videos from all CE, and within 11.5 hours, we received 548 GEARS ratings from crowdworkers. Even though CE were exposed to a training module, internal consistency across videos of CE GEARS ratings remained low (ICC = 0.38). Despite this, we found that crowdworker GEARS ratings of videos were highly correlated with CE ratings at both the video level (R = 0.82, p < 0.001) and surgeon level (R = 0.84, p < 0.001). Similarly, crowdworker ratings of the renal artery dissection were highly correlated with expert assessments (R = 0.83, p < 0.001) for the unique surgery-specific assessment question. We conclude that crowdsourced assessment of qualitative performance ratings may be an alternative and/or adjunct to surgical experts' ratings and would provide a rapid scalable solution to triage technical skills.

Scientific Impact Recognition Award. Sentinel node staging for breast cancer: intraoperative molecular pathology overcomes conventional histologic sampling errors.

PubMed

Blumencranz, Peter; Whitworth, Pat W; Deck, Kenneth; Rosenberg, Anne; Reintgen, Douglas; Beitsch, Peter; Chagpar, Anees; Julian, Thomas; Saha, Sukamal; Mamounas, Eleftherios; Giuliano, Armando; Simmons, Rache

2007-10-01

When sentinel node dissection reveals breast cancer metastasis, completion axillary lymph node dissection is ideally performed during the same operation. Intraoperative histologic techniques have low and variable sensitivity. A new intraoperative molecular assay (GeneSearch BLN Assay; Veridex, LLC, Warren, NJ) was evaluated to determine its efficiency in identifying significant sentinel lymph node metastases (>.2 mm). Positive or negative BLN Assay results generated from fresh 2-mm node slabs were compared with results from conventional histologic evaluation of adjacent fixed tissue slabs. In a prospective study of 416 patients at 11 clinical sites, the assay detected 98% of metastases >2 mm and 88% of metastasis greater >.2 mm, results superior to frozen section. Micrometastases were less frequently detected (57%) and assay positive results in nodes found negative by histology were rare (4%). The BLN Assay is properly calibrated for use as a stand alone intraoperative molecular test.

A prospective investigation of fluorescence imaging to detect sentinel lymph nodes at robotic-assisted endometrial cancer staging.

PubMed

Paley, Pamela J; Veljovich, Dan S; Press, Joshua Z; Isacson, Christina; Pizer, Ellen; Shah, Chirag

2016-07-01

The accuracy of sentinel lymph node mapping has been shown in endometrial cancer, but studies to date have primarily focused on cohorts at low risk for nodal involvement. In our practice, we acknowledge the lack of benefit of lymphadenectomy in the low-risk subgroup and omit lymph node removal in these patients. Thus, our aim was to evaluate the feasibility and accuracy of sentinel node mapping in women at sufficient risk for nodal metastasis warranting lymphadenectomy and in whom the potential benefit of avoiding nodal procurement could be realized. To evaluate the detection rate and accuracy of fluorescence-guided sentinel lymph node mapping in endometrial cancer patients undergoing robotic-assisted staging. One hundred twenty-three endometrial cancer patients undergoing sentinel lymph node sentinel node mapping using indocyanine green were prospectively evaluated. Two mL (1.0 mg/mL) of dye were injected into the cervical stroma divided between the 2-3 and 9-10 o'clock positions at the time of uterine manipulator placement. Before hysterectomy, the retroperitoneal spaces were developed and fluorescence imaging was used for sentinel node detection. Identified sentinel nodes were removed and submitted for touch prep intraoperatively, followed by permanent assessment with routine hematoxylin and eosin levels. Patients then underwent hysterectomy, bilateral salpingo-oophorectomy, and completion bilateral pelvic and periaortic lymphadenectomy based on intrauterine risk factors determined intraoperatively (tumor size >2 cm, >50% myometrial invasion, and grade 3 histology). Of 123 patients enrolled, at least 1 sentinel node was detected in 119 (96.7%). Ninety-nine patients (80%) had bilateral pelvic or periaortic sentinel nodes detected. A total of 85 patients met criteria warranting completion lymphadenectomy. In 14 patients (16%) periaortic lymphadenectomy was not feasible, and the mean number of pelvic nodes procured was 13 (6-22). Of the 71 patients undergoing pelvic and periaortic lymphadenectomy, the mean nodal count was 23.2 (8-51). Of patients undergoing lymphadenectomy, 10.6% had lymph node metastasis on final hematoxylin and eosin evaluation. Notably, the sentinel node was the only positive node in 44% of cases. There were no cases in which final pathology of the sentinel node was negative and metastatic disease was detected upon completion lymphadenectomy in the non-sentinel nodes (no false negatives), yielding a sensitivity of 100%. Of the 14 sentinel nodes ultimately found to harbor metastases, 3 were negative on touch prep, yielding a sensitivity of 78.6% for intraoperative detection of sentinel node involvement. In all 3 of the false-negative touch preps, final pathology detected a single micrometastasis (0.24 mm, 1.4 mm, 1.5 mm). As expected, there were no false-positive results, yielding a specificity of 100%. No complications related to sentinel node mapping or allergic reactions to the dye were encountered. Intraoperative sentinel node mapping using fluorescence imaging with indocyanine green in endometrial cancer patients is feasible and yields high detection rates. In our pilot study, sentinel node mapping identified all women with Stage IIIC disease. Low false-negative rates are encouraging, and if confirmed in multi-institutional trials, this approach would be anticipated to reduce the morbidity, operative times, and costs associated with complete pelvic and periaortic lymphadenectomy. Copyright © 2015 Elsevier Inc. All rights reserved.

Role of Neck Dissection in Clinical T3N0M0 Lesion of Oral Cavity: Changing Trend.

PubMed

Dass, Arjun; Singhal, Surinder K; Punia, Rps; Gupta, Nitin; Verma, Hitesh; Budhiraja, Shilpi; Salaria, Minakshi

2017-08-01

Neck dissection is an important part in the management of head and neck malignancies especially in terms of control of nodal metastasis. The study is focused on evaluating the profile of lymph nodes in T 3 N 0 M 0 lesion of different subsides of oral cavity. To evaluate the utility of neck dissection in T 3 N 0 M 0 stage of carcinomas of the different region of oral cavity. Ninety patients aged 20 to 70 years underwent treatment for carcinoma of the oral cavity at our center between 2005 and 2013. Of these, 39 patients were stage T 3 N 0 M 0 and underwent excision of the primary lesion with neck dissection. The data were collected retrospectively from hospital record library. These patients were evaluated clinically, radiologically and compared with intra operative finding. Addition of radiotherapy was decided on final histopathology. Out of 39 patients, the site of primary tumour in 21 patients was tongue, in 13 patients was Buccal Mucosa (BM), in 2 patients was lip and in 3 patients was Floor of Mouth (FOM) with tongue. In patients with clinically negative neck nodes, ultrasonography and intra-operative examination revealed the presence of suspicious nodes in 35.9% and 30.7% cases respectively. Occult metastasis in the nodes was identified on histopathological examination in 15 patients (38.5%). A total of 14 patients of carcinoma of tongue and one patient of BM showed positive nodes on histopathology. These patients with positive neck nodes on histopathology, were sent for postoperative radiotherapy. At follow up examination, four patients showed local and distal recurrence and they were managed accordingly. Out of 39 patients, 11 patients of BM, 2 patients of lip, 1 patient of FOM and 6 patients of tongue were disease free in last follow up. Selective neck dissection is an effective therapeutic intervention in patients without clinically involved neck nodes. It can upstage the tumour and additional treatment may be advised. In patients with carcinoma of buccal mucosa and lip, the patients can be kept under regular follow up when biopsy report showed excision with adequate margin and no nodal metastasis.

Port positioning and docking for single-stage totally robotic dissection for rectal cancer surgery with the Si and Xi Da Vinci Surgical System.

PubMed

Toh, James Wei Tatt; Kim, Seon-Hahn

2017-11-04

We have previously reported our technique of single-docking totally robotic dissection for rectal cancer surgery using the Da Vinci ® Si Surgical System in 2009. However, we have since optimised our port placement for the Si system and have developed a novel configuration of port placement and docking for the Da Vinci ® Xi Surgical System. We have performed over 700 cases using this technique with the Si system and have used our Xi technique since 2016 for totally robotic dissection for rectal cancer. We have kept the configuration of port placements for both the Xi and Si system as similar as possible, with the priorities to avoid arm collisions as well as to provide a workable port configuration of two left-handed instruments and one right-handed instrument. To date, there have had no major complications or arm collisions related to this technique of docking, port positioning and instrument placement.

A multi-sensor RSS spatial sensing-based robust stochastic optimization algorithm for enhanced wireless tethering.

PubMed

Parasuraman, Ramviyas; Fabry, Thomas; Molinari, Luca; Kershaw, Keith; Di Castro, Mario; Masi, Alessandro; Ferre, Manuel

2014-12-12

The reliability of wireless communication in a network of mobile wireless robot nodes depends on the received radio signal strength (RSS). When the robot nodes are deployed in hostile environments with ionizing radiations (such as in some scientific facilities), there is a possibility that some electronic components may fail randomly (due to radiation effects), which causes problems in wireless connectivity. The objective of this paper is to maximize robot mission capabilities by maximizing the wireless network capacity and to reduce the risk of communication failure. Thus, in this paper, we consider a multi-node wireless tethering structure called the "server-relay-client" framework that uses (multiple) relay nodes in between a server and a client node. We propose a robust stochastic optimization (RSO) algorithm using a multi-sensor-based RSS sampling method at the relay nodes to efficiently improve and balance the RSS between the source and client nodes to improve the network capacity and to provide redundant networking abilities. We use pre-processing techniques, such as exponential moving averaging and spatial averaging filters on the RSS data for smoothing. We apply a receiver spatial diversity concept and employ a position controller on the relay node using a stochastic gradient ascent method for self-positioning the relay node to achieve the RSS balancing task. The effectiveness of the proposed solution is validated by extensive simulations and field experiments in CERN facilities. For the field trials, we used a youBot mobile robot platform as the relay node, and two stand-alone Raspberry Pi computers as the client and server nodes. The algorithm has been proven to be robust to noise in the radio signals and to work effectively even under non-line-of-sight conditions.

A Multi-Sensor RSS Spatial Sensing-Based Robust Stochastic Optimization Algorithm for Enhanced Wireless Tethering

PubMed Central

Parasuraman, Ramviyas; Fabry, Thomas; Molinari, Luca; Kershaw, Keith; Di Castro, Mario; Masi, Alessandro; Ferre, Manuel

2014-01-01

The reliability of wireless communication in a network of mobile wireless robot nodes depends on the received radio signal strength (RSS). When the robot nodes are deployed in hostile environments with ionizing radiations (such as in some scientific facilities), there is a possibility that some electronic components may fail randomly (due to radiation effects), which causes problems in wireless connectivity. The objective of this paper is to maximize robot mission capabilities by maximizing the wireless network capacity and to reduce the risk of communication failure. Thus, in this paper, we consider a multi-node wireless tethering structure called the “server-relay-client” framework that uses (multiple) relay nodes in between a server and a client node. We propose a robust stochastic optimization (RSO) algorithm using a multi-sensor-based RSS sampling method at the relay nodes to efficiently improve and balance the RSS between the source and client nodes to improve the network capacity and to provide redundant networking abilities. We use pre-processing techniques, such as exponential moving averaging and spatial averaging filters on the RSS data for smoothing. We apply a receiver spatial diversity concept and employ a position controller on the relay node using a stochastic gradient ascent method for self-positioning the relay node to achieve the RSS balancing task. The effectiveness of the proposed solution is validated by extensive simulations and field experiments in CERN facilities. For the field trials, we used a youBot mobile robot platform as the relay node, and two stand-alone Raspberry Pi computers as the client and server nodes. The algorithm has been proven to be robust to noise in the radio signals and to work effectively even under non-line-of-sight conditions. PMID:25615734

Robotic, laparoscopic and open surgery for gastric cancer compared on surgical, clinical and oncological outcomes: a multi-institutional chart review. A study protocol of the International study group on Minimally Invasive surgery for GASTRIc Cancer—IMIGASTRIC

PubMed Central

Desiderio, Jacopo; Jiang, Zhi-Wei; Nguyen, Ninh T; Zhang, Shu; Reim, Daniel; Alimoglu, Orhan; Azagra, Juan-Santiago; Yu, Pei-Wu; Coburn, Natalie G; Qi, Feng; Jackson, Patrick G; Zang, Lu; Brower, Steven T; Kurokawa, Yukinori; Facy, Olivier; Tsujimoto, Hironori; Coratti, Andrea; Annecchiarico, Mario; Bazzocchi, Francesca; Avanzolini, Andrea; Gagniere, Johan; Pezet, Denis; Cianchi, Fabio; Badii, Benedetta; Novotny, Alexander; Eren, Tunc; Leblebici, Metin; Goergen, Martine; Zhang, Ben; Zhao, Yong-Liang; Liu, Tong; Al-Refaie, Waddah; Ma, Junjun; Takiguchi, Shuji; Lequeu, Jean-Baptiste; Trastulli, Stefano; Parisi, Amilcare

2015-01-01

Introduction Gastric cancer represents a great challenge for healthcare providers and requires a multidisciplinary treatment approach in which surgery plays a major role. Minimally invasive surgery has been progressively developed, first with the advent of laparoscopy and recently with the spread of robotic surgery, but a number of issues are currently being debated, including the limitations in performing an effective extended lymph node dissection, the real advantages of robotic systems, the role of laparoscopy for Advanced Gastric Cancer, the reproducibility of a total intracorporeal technique and the oncological results achievable during long-term follow-up. Methods and analysis A multi-institutional international database will be established to evaluate the role of robotic, laparoscopic and open approaches in gastric cancer, comprising of information regarding surgical, clinical and oncological features. A chart review will be conducted to enter data of participants with gastric cancer, previously treated at the participating institutions. The database is the first of its kind, through an international electronic submission system and a HIPPA protected real time data repository from high volume gastric cancer centres. Ethics and dissemination This study is conducted in compliance with ethical principles originating from the Helsinki Declaration, within the guidelines of Good Clinical Practice and relevant laws/regulations. A multicentre study with a large number of patients will permit further investigation of the safety and efficacy as well as the long-term outcomes of robotic, laparoscopic and open approaches for the management of gastric cancer. Trial registration number NCT02325453; Pre-results. PMID:26482769

Pattern of node metastases in patients treated with radical cystectomy and extended or superextended pelvic lymph node dissection due to bladder cancer.

PubMed

Moschini, Marco; Arbelaez, Emilio; Cornelius, Julian; Mattei, Agostino; Shariat, Shahrokh F; Dell Oglio, Paolo; Zaffuto, Emanuele; Salonia, Andrea; Montorsi, Francesco; Briganti, Alberto; Colombo, Renzo; Gallina, Andrea

2018-06-01

Pelvic lymph node dissection (PLND) has a diagnostic and therapeutic role during radical cystectomy in bladder cancer patients. However, at the time, no prospective data supports the value of extended PLND in improving survival expectances. We sought to describe incidence and location of node metastases in patients treated with extended and superextended PLND. We evaluated 653 contemporary patients with clinically nonmetastatic high risk nonmuscle invasive or muscle-invasive bladder cancer treated with radical cystectomy and extended or superextended PLND without neoadjuvant chemotherapy at a single tertiary referral center between 1990 and 2013. Limited PLND is defined as the removal of obturator and internal iliac nodes. Standard included also the external iliac nodes. Extended includes also common and presacral nodes. Finally, superextended PLND includes all the nodes removed along the inferior mesenteric artery. We evaluated incidence of pathologically node metastases. Logistic regression analyses evaluate preoperative and pathologic characteristics to the risk of harboring node metastases in the extended and superextended template. Overall, 191 (29.3%) patients were found with pathologically node confirmed metastases. Of these, 56 (29.3%) patients were found with a single node metastasis, while 135 (70.7%) had multiple node metastases. The vast majority of patients were found with node metastases standard template (n = 172, 26.3%), on the other hand 30 (4.6%) and 21 (3.2%) patients had node metastases in extended and superextended templates, respectively. However, of these only 2 patients were found without concomitant lymph node metastases in the limited or standard templates. On multivariable analyses, cN+ status (odds ratio = 4.40, P<0.001) and cT3-4 vs. cT1-2 (odds ratio = 2.25, P<0.001) were associated with an increased risk of harboring node metastases in the extended or superextended template. We found that the majority of patients harbored node disease in the limited or standard node dissection pattern. On the other hand, only a minority of patient were found with a disease in extended or superextended template without harboring a concomitant node disease in the limited pattern. Copyright © 2018 Elsevier Inc. All rights reserved.

The Role of Central Neck Lymph Node Dissection in the Management of Papillary Thyroid Cancer.

PubMed

Shirley, Lawrence A; Jones, Natalie B; Phay, John E

2017-01-01

Papillary thyroid cancer (PTC) is the most common thyroid malignancy, and cervical nodal metastases are frequent at presentation. The most common site for nodal metastases from PTC is the central compartment of the ipsilateral neck in the paratracheal and pretracheal regions. The decision to resect these lymph nodes at the time of thyroidectomy often depends on if nodes with suspected malignancy can be identified preoperatively. If nodal spread to the central neck nodes is known, then the consensus is to remove all nodes in this area. However, there remains significant controversy regarding the utility of removing central neck lymph nodes for prophylactic reasons. Herein, we review the potential utility of central neck lymph node dissection as well as the risks of performing this procedure. As well, we review the potential of molecular testing to stratify patients who would most benefit from this procedure. We advocate a selective approach in which patients undergo clinical neck examination coupled with ultrasound to detect any concerning lymph nodes that warrant additional evaluation with either fine needle aspiration or excisional biopsy in the operating room. In lieu of clinical lymphadenopathy, we suggest the use of patient and disease characteristics as identified by multiple groups, such as the American Thyroid Association and European Society of Endocrine Surgeons, which include extremes of ages, large primary tumor size, and male gender, when deciding to perform central neck lymph node dissection. Patients should be educated on the potential long-terms risks versus the lack of known long-term benefits.

[Application of digital 3D technique combined with nanocarbon-aided navigation in endoscopic sentinel lymph node biopsy for breast cancer].

PubMed

Zhang, Pu-Sheng; Luo, Yun-Feng; Yu, Jin-Long; Fang, Chi-Hua; Shi, Fu-Jun; Deng, Jian-Wen

2016-08-20

To study the clinical value of digital 3D technique combined with nanocarbon-aided navigation in endoscopic sentinel lymph node biopsy for breast cancer. Thirty-nine female patients with stage I/II breast cancer admitted in our hospital between September 2014 and September 2015 were recruited. CT lymphography data of the patients were segmented to reconstruct digital 3D models, which were imported into FreeForm Modeling Surgical System Platform for visual simulation surgery before operation. Endoscopic sentinel lymph node biopsy and endoscopic axillary lymph node dissection were then carried out, and the accuracy and clinical value of digital 3D technique in endoscopic sentinel lymph node biopsy were analyzed. s The 3D models faithfully represented the surgical anatomy of the patients and clearly displayed the 3D relationship among the sentinel lymph nodes, axillary lymph nodes, axillary vein, pectoralis major, pectoralis minor muscle and latissimus dorsi. In the biopsy, the detection rate of sentinel lymph nodes was 100% in the patients with a coincidence rate of 87.18% (34/39), a sensitivity of 91.67% (11/12), and a false negative rate of 8.33% (1/12). Complications such as limb pain, swelling, wound infection, and subcutaneouseroma were not found in these patients 6 months after the operation. Endoscopic sentinel lymph node biopsy assisted by digital 3D technique and nanocarbon-aided navigation allows a high detection rate of sentinel lymph nodes with a high sensitivity and a low false negative rate and can serve as a new method for sentinel lymph node biopsy for breast cancer.

A prediction tool incorporating the biomarker S-100B for patient selection for completion lymph node dissection in stage III melanoma.

PubMed

Damude, S; Wevers, K P; Murali, R; Kruijff, S; Hoekstra, H J; Bastiaannet, E

2017-09-01

Completion lymph node dissection (CLND) in sentinel node (SN)-positive melanoma patients is accompanied with morbidity, while about 80% yield no additional metastases in non-sentinel nodes (NSNs). A prediction tool for NSN involvement could be of assistance in patient selection for CLND. This study investigated which parameters predict NSN-positivity, and whether the biomarker S-100B improves the accuracy of a prediction model. Recorded clinicopathologic factors were tested for their association with NSN-positivity in 110 SN-positive patients who underwent CLND. A prediction model was developed with multivariable logistic regression, incorporating all predictive factors. Five models were compared for their predictive power by calculating the Area Under the Curve (AUC). A weighted risk score, 'S-100B Non-Sentinel Node Risk Score' (SN-SNORS), was derived for the model with the highest AUC. Besides, a nomogram was developed as visual representation. NSN-positivity was present in 24 (21.8%) patients. Sex, ulceration, number of harvested SNs, number of positive SNs, and S-100B value were independently associated with NSN-positivity. The AUC for the model including all these factors was 0.78 (95%CI 0.69-0.88). SN-SNORS was the sum of scores for the five parameters. Scores of ≤9.5, 10-11.5, and ≥12 were associated with low (0%), intermediate (21.0%) and high (43.2%) risk of NSN involvement. A prediction tool based on five parameters, including the biomarker S-100B, showed accurate risk stratification for NSN-involvement in SN-positive melanoma patients. If validated in future studies, this tool could help to identify patients with low risk for NSN-involvement. Copyright © 2017 Elsevier Ltd, BASO ~ The Association for Cancer Surgery, and the European Society of Surgical Oncology. All rights reserved.

Partial axillary lymph node dissection inferior to the intercostobrachial nerves complements sentinel node biopsy in patients with clinically node-negative breast cancer.

PubMed

Li, Jianyi; Jia, Shi; Zhang, Wenhai; Qiu, Fang; Zhang, Yang; Gu, Xi; Xue, Jinqi

2015-06-30

The practice of breast cancer diagnosis and treatment in China varies to that in western developed countries. With the unavailability of radioactive tracer technique for sentinel lymph nodes biopsy (SLNB), using blue dye alone has been the only option in China. Also, the diagnosis of breast malignant tumor in most Chinese centres heavily relies on intraoperative instant frozen histology which is normally followed by sentinel lymph nodes mapping, SLNB and the potential breast and axillary operations in one consecutive session. This practice appears to cause a high false negative rate (FNR) for SLNB. The present study aimed to investigate the impact of the current practice in China on the accuracy of SLNB, and whether partial axillary lymph node dissection (PALND), dissection of lymph nodes inferior to the intercostobrachial nerve (ICBN), was a good complementary procedure following SLNB using blue dye. 289 patients with clinically node-negative breast cancer were identified and recruited. Tumorectomy, intraoperative instant frozen histological diagnosis, SLNB using methylene blue dye, and PALND or complete axillary node dissection (ALND) were performed in one consecutive operative session. The choice of SLNB only, SLNB followed by PALND or by ALND was based on the pre-determined protocol and preoperative choice by the patient. Clinical parameters were analyzed and survival analysis was performed. 37% patients with clinically negative nodes were found nodes positive. 59 patients with positive SLN underwent ALND, including 47 patients with up to two positive nodes which were all located inferior to the ICBN. 9 patients had failed SLNB and underwent PALND. Among them, 3 (33.3%) patients were found to have one metastatic node. 149 patients showed negative SLNB but chose PALND. Among them, 30 (20.1%), 14 (9.4) and 1 (0.7%) patients were found to have one, two and three metastatic node(s), respectively. PALND detected 48 (30.4%) patients who had either failed SLNB or negative SLNB to have additional positive nodes. All the patients with up to two positive nodes had their nodes located inferior to the ICBN. The FNR of SLNB was 43%. The accuracy rate was 58%. The follow-up ranged 12-33 months. The incidence of lymphedema for SLNB, PALND, and ALND was 0%, 0%, and 25.4%, respectively (P < 0.005). The disease-free survivals for SLNB, PALND, and ALND groups were 95.8%, 96.8%, and 94.9%, respectively (p > 0.05). Under the circumstances of current practice in China, PALND is a good complementary procedure following SLNB in clinically node-negative breast cancer.

[A Case of Lymph Node Metastasis of Rectal Laterally Spreading Tumor with Mucosal Cancer after Endoscopic Submucosal Dissection].

PubMed

Ushigome, Hajime; Fujimoto, Yoshiya; Suzuki, Shinsuke; Minami, Hironori; Miyanari, Shun; Murahashi, Satoshi; Fukuoka, Hironori; Nagasaki, Toshiya; Akiyoshi, Takashi; Konishi, Tsuyoshi; Nagayama, Satoshi; Fukunaga, Yosuke; Ueno, Masashi; Chino, Akiko; Igarashi, Masahiro

2017-11-01

A screening fecal occult blood test was positive in a 76-year-old female. Colonoscopy showed laterally spreading tumor (LST)over 15 cm at lower rectum. endoscopic submucosal dissection(ESD)was performed. Pathological findings showed LST-G, 150×100 mm, adenocarcinoma(tub1-tub2), tubular adenoma, moderate-severe atypia, Tis(M), ly(-), v(-), HMX, VMX. Two years later CT detected one swollen lymph node at mesorectum and PET-CT showed FDG up take at the lymph node. We diagnosed lymph node metastasis, performed laparoscopic very low anterior resection. Pathological findings showed one lymph node metastasis, but there were no residual cancer at rectum. We cut the surgical specimen at 5mm intervals because of it's big size. It might be impossible with this procedure to detect SM invasion at this specimen.

Feasibility and Learning Curve of Robotic Laparoendoscopic Single-Site Surgery in Gynecology.

PubMed

Buckley de Meritens, Alexandre; Kim, Julia; Dinkelspiel, Helen; Chapman-Davis, Eloise; Caputo, Thomas; Holcomb, Kevin M

2017-02-01

Single-site laparoscopy has proven to be a desirable option for patients undergoing gynecologic surgery, with some studies indicating improved cosmesis and less perioperative pain compared with standard approaches. This study describes the safety and feasibility of a novel robotic laparoendoscopic single-site surgery (R-LESS) platform as it is incorporated into a surgeon's practice with extensive multiport robotic surgical experience but limited LESS experience. We reviewed 83 women undergoing R-LESS by a single surgeon from September 2013 through August 2015. Operative times (total operative time, console time, docking time) were collected prospectively for the first 53 cases, and total operative time was collected retrospectively for the next 30 cases. Clinical parameters, including age, estimated blood loss, body mass index (BMI), prior abdominal surgeries, conversion to laparotomy, procedure type, uterine weight, length of hospital stay, and complications, were retrospectively collected from medical charts. Eighty-two of 83 surgeries were completed successfully with a single incision. One surgery was converted to multiport robotics for para-aortic lymph node dissection. Twelve surgeries were performed for cancer (ovary 1, uterus 8, and cervix 3). Eight patients underwent pelvic lymph node biopsy. The median total operative time for hysterectomies was 128 minutes (range, 60-275). After the first 13 hysterectomies the total operative time and the console time decreased significantly from 165.3 to 131.1 minutes (p = .032) and from 84.9 to 57.1 minutes (p = .028), respectively. Mean docking time halved from 7.8 minutes to 3.4 minutes comparing the first 10 cases to the last 10 cases. Surgical times were longer with larger BMIs, but the console time decreased with experience regardless of BMI. The mean uterine weight was 164 g (range, 30-460). Complications included 2 umbilical hernias (2.4%) and 1 conversion to multiport. In conclusion, R-LESS is a feasible and safe surgical platform for gynecologic procedures. A small number of cases are needed to significantly improve operative times when it is introduced on a surgeon's practice with limited experience in LESS but familiar with robotic surgery. Further study is needed to investigate the cost, benefits, and long-term outcomes of R-LESS. Published by Elsevier Inc.

SafeNet: a methodology for integrating general-purpose unsafe devices in safe-robot rehabilitation systems.

PubMed

Vicentini, Federico; Pedrocchi, Nicola; Malosio, Matteo; Molinari Tosatti, Lorenzo

2014-09-01

Robot-assisted neurorehabilitation often involves networked systems of sensors ("sensory rooms") and powerful devices in physical interaction with weak users. Safety is unquestionably a primary concern. Some lightweight robot platforms and devices designed on purpose include safety properties using redundant sensors or intrinsic safety design (e.g. compliance and backdrivability, limited exchange of energy). Nonetheless, the entire "sensory room" shall be required to be fail-safe and safely monitored as a system at large. Yet, sensor capabilities and control algorithms used in functional therapies require, in general, frequent updates or re-configurations, making a safety-grade release of such devices hardly sustainable in cost-effectiveness and development time. As such, promising integrated platforms for human-in-the-loop therapies could not find clinical application and manufacturing support because of lacking in the maintenance of global fail-safe properties. Under the general context of cross-machinery safety standards, the paper presents a methodology called SafeNet for helping in extending the safety rate of Human Robot Interaction (HRI) systems using unsafe components, including sensors and controllers. SafeNet considers, in fact, the robotic system as a device at large and applies the principles of functional safety (as in ISO 13489-1) through a set of architectural procedures and implementation rules. The enabled capability of monitoring a network of unsafe devices through redundant computational nodes, allows the usage of any custom sensors and algorithms, usually planned and assembled at therapy planning-time rather than at platform design-time. A case study is presented with an actual implementation of the proposed methodology. A specific architectural solution is applied to an example of robot-assisted upper-limb rehabilitation with online motion tracking. Copyright © 2014 Elsevier Ireland Ltd. All rights reserved.

Robotic surgery

MedlinePlus

Robot-assisted surgery; Robotic-assisted laparoscopic surgery; Laparoscopic surgery with robotic assistance ... computer station and directs the movements of a robot. Small surgical tools are attached to the robot's ...

Transoral robotic surgery for neurogenic tumors of the prestyloid parapharyngeal space.

PubMed

Lee, Hyoung Shin; Kim, Jinna; Lee, Hyun Jin; Koh, Yoon Woo; Choi, Eun Chang

2012-08-01

The parapharyngeal space is a difficult area for a surgical approach due to anatomical complexity. We performed a minimally invasive and precise surgical technique to remove neurogenic tumors of the prestyloid parapharyngeal space using transoral robotic instrumentation. The mass was successfully removed in the two cases with three-dimensional visualization providing an excellent view of the resection margin and the dissection plane preserving the vital structures. An adequate resection margin was acquired, and no violation of the tumor capsule occurred. No significant complications were noted. Transoral robotic surgery was feasible for neurogenic tumors of the prestyloid parapharyngeal space, providing a sufficient resection margin and delicate dissection through excellent surgical views and instrumentation. Copyright © 2012. Published by Elsevier Ireland Ltd.

Robotic Y-V Plasty for Recalcitrant Bladder Neck Contracture.

PubMed

Granieri, Michael A; Weinberg, Aaron C; Sun, Jeffrey Y; Stifleman, Michael; Zhao, Lee

2018-07-01

To demonstrate the technique and the outcomes of robot assisted Y-V plasty bladder neck reconstruction (RYVBNR). We present our technique for treatment of recalcitrant bladder neck contracture (BNC) in 7 patients who underwent RYVBNR at our institution between March 2016 and September 2017. Indication for the procedure was incomplete emptying, recurrent urinary tract infections, and dysuria. On follow-up, patients were assessed for clinical success by absence of infections, symptoms, and cystoscopic evaluation. Robotic assisted dissection is performed to open the space of Retzius and mobilize the bladder. The cystoscope is passed to the level of the BNC, and Firefly technology is used to localize the BNC. The BNC is incised anteriorly, and a V-shaped bladder flap is advanced into the BNC in a Y-V plasty fashion. We place a perioperative closed suction drain, which is removed before discharge, and a 22 Fr catheter, which that will be removed in the office at approximately 2 weeks. Six men developed recalcitrant BNCs and 1 developed a recalcitrant vesicourethral anastomotic stenosis. All patients had previously undergone an endoscopic procedure. Median time for last attempt at endoscopic management to robot-assisted bladder neck repair was 4.7 months. The average number of prior attempts at endoscopic management was 2. All patients underwent RYVBNR without conversion to open surgery. The median operative time was 240 minutes, estimated blood loss was 67 mL, and length of stay was 1 day. There were no intraoperative complications. Catheters were removed in the office at a median time of 15 days. At a median follow-up of 8 months, all cases were successful with no evidence of recurrence. Only 2 patients had persistent urinary incontinence at 1 pad per day. RYVBNR with a Y-V plasty is a feasible and effective technique for managing a difficult reconstructive problem. Copyright © 2018 Elsevier Inc. All rights reserved.

Three-dimensional computer-assisted dissection of pancreatic lymphatic anatomy on human fetuses: a step toward automatic image alignment.

PubMed

Bardol, T; Subsol, G; Perez, M-J; Genevieve, D; Lamouroux, A; Antoine, B; Captier, G; Prudhomme, M; Bertrand, M M

2018-05-01

Pancreatic cancer is the fourth cause of death by cancer worldwide. Lymph node (LN) involvement is known to be the main prognostic factor. However, lymphatic anatomy is complex and only partially characterized. The aim of the study was to study the pancreatic lymphatic system using computer-assisted anatomic dissection (CAAD) technique and also to update CAAD technique by automatizing slice alignment. We dissected three human fetuses aged from 18 to 34 WA. 5-µm serial sections of duodeno-pancreas and spleen blocks were stained (hematoxylin-eosin, hematoxylin of Mayer and Masson trichrome), scanned, aligned and modeled in three dimensions. We observed a rich, diffuse but not systematized lymphatic network in the peri-pancreatic region. There was an equal distribution of LNs between the cephalic and body-tail portions. The lymphatic vascularization appeared in continuity from the celiac trunk to the distal ends of its hepatic and splenic arterial branches parallel to the nerve ramifications of the celiac plexus. We also observed a continuity between the drainage of the pancreatic head and the para-aortic region posteriorly. In view of the wealth of peri-pancreatic LNs, the number of LNs to harvest could be increased to improve nodal staging and prognostic evaluation. Pancreatic anatomy as described does not seem to be compatible with the sentinel LN procedure in pancreatic surgery. Finally, we are now able to offer an alternative to manual alignment with a semi-automated alignment.

The impact of superficial injections of radiocolloids and dynamic lymphoscintigraphy on sentinel node identification in oral cavity cancer: a same-day protocol.

PubMed

Tartaglione, Girolamo; Vigili, Maurizio G; Rahimi, Siavash; Celebrini, Alessandra; Pagan, Marco; Lauro, Luigi; Al-Nahhas, Adil; Rubello, Domenico

2008-04-01

To evaluate the role of dynamic lymphoscintigraphy with a same-day protocol for sentinel node biopsy in oral cavity cancer. Twenty-two consecutive patients affected by cT1-2N0 squamous cell carcinoma of the oral cavity were enrolled between September 2001 and November 2005. After a local anaesthetic (10% lidocaine spray), a dose of 30-50 MBq of Tc human serum albumin nanocolloid, in ml saline, was injected superficially (1-2 mm subendothelial injection) into four points around the lesion. Dynamic lymphoscintigraphy was acquired immediately (256x256 matrix, 5 min pre-set time, LEGP collimator) in lateral and anterior projections. The imaging was prolonged until the lymph nodes of at least two neck levels were visualized (time required min). About 3 h later (same-day protocol) the patients had a radioguided sentinel node biopsy. Elective neck dissection was performed in the first 13 patients; whereas the last nine patients had elective neck dissection only if the sentinel node was positive. Sentinel nodes were dissected into 1 mm thick block sections and studied by haematoxylin & eosin staining and immunohistochemistry (anticytokeratin antibody). The sentinel nodes were found on the 1st neck level in 13 cases, on the 2nd neck level in eight cases, and on the 3rd neck level in one case (100% sensitivity). The average number of sentinel nodes was 2.2 for each patient. The sentinel node was positive in eight patients (36%); with six of them having the sentinel node as the exclusive site of metastasis. No skip metastases were found in the 14 patients with negative sentinel node (100% specificity). Our preliminary data indicate that superficial injections of radiocolloid and dynamic lymphoscintigraphy provide a high success rate in sentinel node identification in oral cavity cancers. Dynamic lymphoscintigraphy helps in distinguishing sentinel node from second-tier lymph nodes. The same-day protocol is advisable in order to correctly identify the first sentinel node, avoiding multiple and unnecessary node biopsies, without reducing sensitivity.

Comparison Between Minimally Invasive and Open Pancreaticoduodenectomy: A Systematic Review.

PubMed

Doula, Chrysoula; Kostakis, Ioannis D; Damaskos, Christos; Machairas, Nikolaos; Vardakostas, Dimitrios V; Feretis, Themistoklis; Felekouras, Evangelos

2016-02-01

Minimally invasive approaches (laparoscopic or robotic) are used in various operations. Our aim was to compare them with the open approach in pancreaticoduodenectomy. We conducted a search for articles published in MEDLINE database comparing minimally invasive (laparoscopic or robotic) with open pancreaticoduodenectomy on June 15, 2014. Our search yielded 136 articles. We excluded 122 articles and we took into consideration 14 (10 for laparoscopic and 4 for robotic pancreaticoduodenectomies). Most cases were related to malignant diseases and tumors treated with minimally invasive operations tended to be smaller. There were relatively high conversion rates in both laparoscopic (0% to 15%) and robotic procedures (4.5% to 10%). There were no significant differences regarding resection margins, rates of pancreatic fistula formation, bile leak, and delayed gastric emptying, reoperation rates, and intraoperative and postoperative mortality. On the contrary, blood loss was less in minimally invasive than open operations, although this difference was not always significant. Moreover, totally laparoscopic and robotic procedures lasted longer than the open ones, whereas hand-assisted laparoscopic procedures did not. However, the findings regarding the number of the retrieved lymph nodes, the length of hospital stay, and costs were inconclusive and controversial. Laparoscopic and robotic pancreaticoduodenectomy are feasible, safe, and oncologically equivalent alternatives to open pancreaticoduodenectomy. Minimally invasive operations have the advantage of the less blood loss, but totally laparoscopic and robotic procedures last longer than open procedures.

Cost-Effectiveness Analysis of Elective Neck Dissection in Patients With Clinically Node-Negative Oral Cavity Cancer.

PubMed

Acevedo, Joseph R; Fero, Katherine E; Wilson, Bayard; Sacco, Assuntina G; Mell, Loren K; Coffey, Charles S; Murphy, James D

2016-11-10

Purpose Recently, a large randomized trial found a survival advantage among patients who received elective neck dissection in conjunction with primary surgery for clinically node-negative oral cavity cancer compared with those receiving primary surgery alone. However, elective neck dissection comes with greater upfront cost and patient morbidity. We present a cost-effectiveness analysis of elective neck dissection for the initial surgical management of early-stage oral cavity cancer. Methods We constructed a Markov model to simulate primary, adjuvant, and salvage therapy; disease recurrence; and survival in patients with T1/T2 clinically node-negative oral cavity squamous cell carcinoma. Transition probabilities were derived from clinical trial data; costs (in 2015 US dollars) and health utilities were estimated from the literature. Incremental cost-effectiveness ratios, expressed as dollar per quality-adjusted life-year (QALY), were calculated with incremental cost-effectiveness ratios less than $100,000/QALY considered cost effective. We conducted one-way and probabilistic sensitivity analyses to examine model uncertainty. Results Our base-case model found that over a lifetime the addition of elective neck dissection to primary surgery reduced overall costs by $6,000 and improved effectiveness by 0.42 QALYs compared with primary surgery alone. The decrease in overall cost despite the added neck dissection was a result of less use of salvage therapy. On one-way sensitivity analysis, the model was most sensitive to assumptions about disease recurrence, survival, and the health utility reduction from a neck dissection. Probabilistic sensitivity analysis found that treatment with elective neck dissection was cost effective 76% of the time at a willingness-to-pay threshold of $100,000/QALY. Conclusion Our study found that the addition of elective neck dissection reduces costs and improves health outcomes, making this a cost-effective treatment strategy for patients with early-stage oral cavity cancer.

Axillary lymph nodes and arm lymphatic drainage pathways are spared during routine complete axillary clearance in majority of women undergoing breast cancer surgery.

PubMed

Szuba, A; Chachaj, Z; Koba-Wszedybylb, M; Hawro, R; Jasinski, R; Tarkowski, R; Szewczyk, K; Bebenek, M; Forgacz, J; Jodkowska, A; Jedrzejuk, D; Janczak, D; Mrozinska, M; Pilch, U; Wozniewski, M

2011-09-01

Alterations in axillary lymph nodes (ALNs) after complete axillary lymph node dissection (ALND) in comparison to the preoperative status were evaluated using lymphoscintigraphy performed preoperatively and 1-6 weeks after surgery in 30 women with a new diagnosis of unilateral, invasive breast carcinoma. Analysis of lymphoscintigrams revealed that ALNs after surgery were present in 26 of 30 examined women. In comparison to preoperative status, they were visualized in the same location (12 women), in the same and additionally in different locations (9 women), or only in different locations (4 women). No lymph nodes were visualized in one woman and lymphocoele were in 4 women. Thus, after ALND, a variable number of axillary lymph nodes remain and were visualized on lymphoscintigraphy in the majority of women. The classical ALND, therefore, does not allow complete dissection and removal of axillary nodes with total disruption of axillary lymphatic pathways, accounting in part for the variable incidence and severity of lymphedema after the procedure.

Robotic Thyroidectomy: Comparison of a Postauricular Facelift Approach with a Gasless Unilateral Axillary Approach.

PubMed

Sung, Eui Suk; Ji, Yong Bae; Song, Chang Myeon; Yun, Bo Ram; Chung, Won Sang; Tae, Kyung

2016-06-01

Robotic thyroidectomy using remote access approaches has gained popularity with patients seeking to avoid neck scarring and enhanced cosmetic satisfaction. The aim of this study was to compare the efficacy and advantages of a postauricular facelift approach vs a gasless unilateral axillary (GUA) approach in robotic thyroidectomy. Case series with chart review. University tertiary care hospital. We retrospectively analyzed the data of 65 patients who underwent robotic thyroidectomy with or without central neck dissection using a GUA approach (45 patients) or a postauricular facelift approach (20 patients) between September 2013 and December 2014. We excluded patients who underwent simultaneous lateral neck dissection or completion thyroidectomy. Robotic procedures were completed without being converted to an open procedure in all patients. There were no significant differences in terms of patient and tumor characteristics, extent of thyroidectomy and central neck dissection, operative time, complications, and postoperative pain between the 2 approaches, except the higher female ratio in the GUA approach group (female ratio, 95.6% vs 75%, P = .042). Cosmetic satisfaction evaluated by a questionnaire was not significantly different between the 2 groups, and most patients of both groups (85.7%) were satisfied with postoperative cosmesis. Both GUA and postauricular facelift approaches are feasible, with no significant adverse events in patients, and result in excellent cosmesis. However, a GUA approach seems to be superior when performing total thyroidectomy using a unilateral incision based on the preliminary result. © American Academy of Otolaryngology—Head and Neck Surgery Foundation 2016.

Megasessions for Robotic Hair Restoration.

PubMed

Pereira, Joa O Carlos; Pereira Filho, Joa O Carlos; Cabrera Pereira, Joa O Pedro

2016-11-01

A robotic system can select and remove individual hair follicles from the donor area with great precision and without fatigue. This report describes the use of the robotic system in a megasession for hair restoration. Patients were instructed to cut their hair to 1.0 to 1.2 mm before surgery. The robot selected and removed 600 to 800 grafts per hour so the follicular units (FU)s could be transplanted manually to recipient sites. The robot arm consists of a sharp inner punch and a blunt outer punch which together separate FUs from the sur- rounding tissue. Stereoscopic cameras controlled by image processing software allow the system to identify the angle and direction of hair growth. The physician and one assistant control the harvesting with a hand-held remote control and computer monitor while the patient is positioned in an adjustable chair. When the robot has harvested all the FUs they are removed by technicians with small forceps. Hairline design, creation of recipient sites, and graft placement are performed manually by the physician. Clinical photographs before and after surgery show that patients experience excellent outcomes with the robotic megasession. Phy- sician fatigue during graft extraction is reduced because the robot performs the repetitive movements without fatigue. Variability of graft extraction is minimized because the robot's optical system can be programmed to choose the best FUs. The transection rate is reduced because the robot's graft extraction system uses two needles, a sharp one to piece the skin and a blunt needle to dissect the root without trauma. A robotic megasession for hair restoration is minimally invasive, does not result in linear scars in the donor area, and is associated with minimal fatigue and discomfort for both patient and physician. Healing is rapid and patients experience a high level of satisfaction with the results. J Drugs Dermatol. 2016;15(11):1407-1412..

A standardized technique of systematic mediastinal lymph node dissection by video-assisted thoracoscopic surgery (VATS) leads to a high rate of nodal upstaging in early-stage non-small cell lung cancer.

PubMed

Reichert, Martin; Steiner, Dagmar; Kerber, Stefanie; Bender, Julia; Pösentrup, Bernd; Hecker, Andreas; Bodner, Johannes

2016-03-01

A substantial part of the oncologic surgical procedure in non-small cell lung cancer (NSCLC) is systematic lymph node dissection (sLND). However, controversies still exist regarding the quality of minimally invasive (video-assisted thoracoscopic surgery, VATS) sLND in oncologic resections. The rate of stage migration from clinical to pathological N-status has been discussed as one parameter for the quality of sLND. Between March 2011 and May 2014, seventy-seven patients (62 male, 15 female) were scheduled for anatomical lung resection and sLND by VATS for clinical stage I (UICC 7th edition) NSCLC. Preoperative staging was performed by [18F]-fluorodesoxyglucose positron emission tomography with computed tomography (FDG-PET/CT). Patient data were retrospectively analyzed with regard to divergence in clinical and pathological N-factor. FDG-PET/CTs of patients with lymph node (LN) upstaging after VATS resections were blindly re-evaluated by an experienced radiologist. In FDG-PET/CT, preoperative tumor stage was cT1N0M0 in 41 (53.2%) and cT2aN0M0 in 28 (36.4%) patients. In six (7.8%) patients the primary tumor was not suspicious for malignancy, and in two (2.6%) patients the tumor was not evaluable due to prior wedge resection before FDG-PET/CT. Thirty-one (40.3%) left-sided and 46 (59.7%) right-sided pulmonary resections with sLND were performed; 19.57 ± 0.99 LNs were dissected. In 13 (16.9%) patients a nodal stage migration from preoperative clinical to postoperative pathological N-stage was observed [cN0 to pN1 in 9 (11.7%) and cN0 to pN2 in 4 (5.2%) cases]. In correlation to the clinical T-factor, the rate of N-factor upstaging for cT1 was 12.2% and for cT2a was 28.6%, respectively. In 50% of the patients with postoperative nodal staging shift, no changes were observed on re-evaluation of the preoperative FDG-PET/CT. In this series of clinical stage I NSCLC patients, the rate of nodal stage migration after sLND by VATS is higher than previously reported. Prospective randomized controlled trials are needed to prove the oncologic quality of a sLND by VATS versus standard open approach.

Prognostic Value of p16 Status on the Development of a Complete Response in Involved Oropharynx Cancer Neck Nodes After Cisplatin-Based Chemoradiation: A Secondary Analysis of NRG Oncology RTOG 0129

DOE Office of Scientific and Technical Information (OSTI.GOV)

Galloway, Thomas J., E-mail: thomas.galloway@fccc.edu; Zhang, Qiang; Nguyen-Tan, Phuc Felix

Purpose: To determine the relationship between p16 status and the regional response of patients with node-positive oropharynx cancer treated on NRG Oncology RTOG 0129. Methods and Materials: Patients with N1-N3 oropharynx cancer and known p16 status who underwent treatment on RTOG 0129 were analyzed. Pathologic complete response (pCR) rates in patients treated with a postchemoradiation neck dissection (with p16-positive or p16-negative cancer) were compared by Fisher exact test. Patients managed expectantly were compared with those treated with a neck dissection. Results: Ninety-nine (34%) of 292 patients with node-positive oropharynx cancer and known p16 status underwent a posttreatment neck dissection (p16-positive:more » n=69; p16-negative: n=30). The remaining 193 patients with malignant lymphadenopathy at diagnosis were observed. Neck dissection was performed a median of 70 (range, 17-169) days after completion of chemoradiation. Neither the pretreatment nodal stage (P=.71) nor the postradiation, pre-neck dissection clinical/radiographic neck assessment (P=.42) differed by p16 status. A pCR was more common among p16-positive patients (78%) than p16-negative patients (53%, P=.02) and was associated with a reduced incidence of local–regional failure (hazard ratio 0.33, P=.003). On multivariate analysis of local–regional failure, a test for interaction between pCR and p16 status was not significant (P=.37). One-hundred ninety-three (66%) of 292 of initially node-positive patients were managed without a posttreatment neck dissection. Development of a clinical (cCR) was not significantly influenced by p16-status (P=.42). Observed patients with a clinical nodal CR had disease control outcomes similar to those in patients with a pCR neck dissection. Conclusions: Patients with p16-positive tumors had significantly higher pCR and locoregional control rates than those with p16-negative tumors.« less

Prognostic Value of p16 Status on the Development of a Complete Response in Involved Oropharynx Cancer Neck Nodes After Cisplatin-Based Chemoradiation: A Secondary Analysis of NRG Oncology RTOG 0129.

PubMed

Galloway, Thomas J; Zhang, Qiang Ed; Nguyen-Tan, Phuc Felix; Rosenthal, David I; Soulieres, Denis; Fortin, André; Silverman, Craig L; Daly, Megan E; Ridge, John A; Hammond, J Alexander; Le, Quynh-Thu

2016-10-01

To determine the relationship between p16 status and the regional response of patients with node-positive oropharynx cancer treated on NRG Oncology RTOG 0129. Patients with N1-N3 oropharynx cancer and known p16 status who underwent treatment on RTOG 0129 were analyzed. Pathologic complete response (pCR) rates in patients treated with a postchemoradiation neck dissection (with p16-positive or p16-negative cancer) were compared by Fisher exact test. Patients managed expectantly were compared with those treated with a neck dissection. Ninety-nine (34%) of 292 patients with node-positive oropharynx cancer and known p16 status underwent a posttreatment neck dissection (p16-positive: n=69; p16-negative: n=30). The remaining 193 patients with malignant lymphadenopathy at diagnosis were observed. Neck dissection was performed a median of 70 (range, 17-169) days after completion of chemoradiation. Neither the pretreatment nodal stage (P=.71) nor the postradiation, pre-neck dissection clinical/radiographic neck assessment (P=.42) differed by p16 status. A pCR was more common among p16-positive patients (78%) than p16-negative patients (53%, P=.02) and was associated with a reduced incidence of local-regional failure (hazard ratio 0.33, P=.003). On multivariate analysis of local-regional failure, a test for interaction between pCR and p16 status was not significant (P=.37). One-hundred ninety-three (66%) of 292 of initially node-positive patients were managed without a posttreatment neck dissection. Development of a clinical (cCR) was not significantly influenced by p16-status (P=.42). Observed patients with a clinical nodal CR had disease control outcomes similar to those in patients with a pCR neck dissection. Patients with p16-positive tumors had significantly higher pCR and locoregional control rates than those with p16-negative tumors. Copyright © 2016 Elsevier Inc. All rights reserved.

Robotic-assisted versus open radical cystectomy in bladder cancer: A meta-analysis of four randomized controlled trails.

PubMed

Tang, Jin-Qiu; Zhao, Zhihong; Liang, Yiwen; Liao, Guixiang

2018-02-01

Robot-assisted radical cystectomy (RARC) is increasing annually for treatment of bladder cancer. The objective of this meta-analysis was to compare the safety and efficacy of RARC and open radical cystectomy (ORC) for bladder cancer. Our meta-analysis searches were conducted using PubMed, Web of Science, and Cochrane Library databases to identify randomized controlled trials (RCT) assessing the two techniques. Four RCT studies were identified, including 239 cases. Our studies indicated that RARC was associated with longer operative time (WMD: 69.69, 95% CI:17.25 to122.12; P= 0.009), lower estimated blood loss (WMD: -299.83, 95% CI:-414.66to -184.99; P<0.00001). The two groups had no significant difference in overall perioperative complications, length of hospital stay, lymph node yield and positive surgical margins. RARC is mini-invasive alternative to ORC for bladder cancer. The advantage of RARC was reduced estimated blood loss. More studies are needed to compare the two techniques. Copyright © 2017 John Wiley & Sons, Ltd.

Near-Infrared Lymphatic Mapping of the Recurrent Laryngeal Nerve Nodes in T1 Esophageal Cancer.

PubMed

Park, Seong Yong; Suh, Jee Won; Kim, Dae Joon; Park, Jun Chul; Kim, Eun Hye; Lee, Chang Young; Lee, Jin Gu; Paik, Hyo Chae; Chung, Kyoung Young

2018-06-01

It is still unclear that dissection of recurrent laryngeal nerve nodes is mandatory in patients with cT1 middle or lower thoracic esophageal squamous cell carcinoma when the nodes are negative in preoperative staging workup. We aimed to evaluate the feasibility of near-infrared image-guided lymphatic mapping of bilateral recurrent laryngeal nerve nodes. The day before operation, we injected indocyanine green (ICG) into the submucosal layer by endoscopy. At the time of upper mediastinal dissection, ICG-stained basins were identified along the bilateral recurrent laryngeal nerves and retrieved under guidance of the Firefly system. After the operation, remnant ICG-unstained basins were dissected from the specimen to assess the presence of metastasis. Of 29 patients enrolled, ICG-stained basins could be identified in 25 patients (86.2%), and 6 of them (24.0%) had nodal metastasis; 4 in the right recurrent laryngeal nerve chain, 1 in the left recurrent laryngeal nerve chain, and 1 in both recurrent laryngeal nerve chains. On pathologic examination of 345 recurrent laryngeal nerve nodes, two metastatic nodes were identified in ICG-unstained basins along the left recurrent laryngeal nerve in a patient who had lymph node metastases in ICG-stained basins along both recurrent laryngeal nerves. Negative predictive value in detection of nodal metastasis was 100% for the right recurrent laryngeal nerve chain and 98.2% for the left recurrent laryngeal nerve chain. Real-time assessment of recurrent laryngeal nerve nodes with near-infrared image was technically feasible, and we could detect lymphatic basins that most likely have nodal metastasis. Our technique might be useful in determining the optimal extent of lymphadenectomy. Copyright © 2018 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.

The utility of indocyanine green fluorescence imaging during robotic adrenalectomy.

PubMed

Colvin, Jennifer; Zaidi, Nisar; Berber, Eren

2016-08-01

Indocyanine green (ICG) has been used for medical imaging since 1950s, but has more recently become available for use in minimally invasive surgery owing to improvements in technology. This study investigates the use of ICG florescence to guide an accurate dissection by delineating the borders of adrenal tumors during robotic adrenalectomy (RA). This prospective study compared conventional robotic view with ICG fluorescence imaging in 40 consecutive patients undergoing RA. Independent, non-blinded observers assessed how accurately ICG fluorescence delineated the borders of adrenal tumors compared to conventional robotic view. A total of 40 patients underwent 43 adrenalectomies. ICG imaging was superior, equivalent, or inferior to conventional robotic view in 46.5% (n = 20), 25.6% (n = 11), and 27.9% (n = 12) of the procedures. On univariate analysis, the only parameter that predicted the superiority of ICG imaging over conventional robotic view was the tumor type, with adrenocortical tumors being delineated more accurately on ICG imaging compared to conventional robotic view. This study demonstrates the utility of ICG to guide the dissection and removal of adrenal tumors during RA. A simple reproducible method is reported, with a detailed description of the utility based on tumor type, approach and side. J. Surg. Oncol. 2016;114:153-156. © 2016 Wiley Periodicals, Inc. © 2016 Wiley Periodicals, Inc.

American Thyroid Association consensus review and statement regarding the anatomy, terminology, and rationale for lateral neck dissection in differentiated thyroid cancer.

PubMed

Stack, Brendan C; Ferris, Robert L; Goldenberg, David; Haymart, Megan; Shaha, Ashok; Sheth, Sheila; Sosa, Julie Ann; Tufano, Ralph P

2012-05-01

Cervical lymph node metastases from differentiated thyroid cancer (DTC) are common. Thirty to eighty percent of patients with papillary thyroid cancer harbor lymph node metastases, with the central neck being the most common compartment involved. The goals of this study were to: (1) identify appropriate methods for determining metastatic DTC in the lateral neck and (2) address the extent of lymph node dissection for the lateral neck necessary to control nodal disease balanced against known risks of surgery. A literature review followed by formulation of a consensus statement was performed. Four proposals regarding management of the lateral neck are made for consideration by organizations developing management guidelines for patients with thyroid nodules and DTC including the next iteration of management guidelines developed by the American Thyroid Association (ATA). Metastases to lateral neck nodes must be considered in the evaluation of the newly diagnosed thyroid cancer patient and for surveillance of the previously treated DTC patient. Lateral neck lymph nodes are a significant consideration in the surgical management of patients with DTC. When current guidelines formulated by the ATA and by other international medical societies are followed, initial evaluation of the DTC patient with ultrasound (or other modalities when indicated) will help to identify lateral neck lymph nodes of concern. These findings should be addressed using fine-needle aspiration biopsy. A comprehensive neck dissection of at least nodal levels IIa, III, IV, and Vb should be performed when indicated to optimize disease control.

Anterior subcarinal node dissection on the left side using video thoracoscopy: an easier technique.

PubMed

Baste, Jean-Marc; Haddad, Laura; Melki, Jean; Peillon, Christophe

2015-04-01

Lobectomy for lung carcinoma is usually associated with complete node dissection, but it is often difficult to perform using video thoracoscopy, especially on the left side. In this case, our team uses an anterior technique for subcarinal lymphadenectomy. After left lobectomy, we lift the bronchial stump by its anterior face to open and dissect the subcarinal space. Exposure is difficult using the more usual technique of posterior subcarinal lymphadenectomy, and the different techniques (often requiring retractors) remain complex because some vessels might be injured. We recommend using anterior lymphadenectomy, which should facilitate video thoracoscopy for lymphadenectomy on the left side. Copyright © 2015 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.

Lymph node ratio predicts disease-specific survival in melanoma patients.

PubMed

Xing, Yan; Badgwell, Brian D; Ross, Merrick I; Gershenwald, Jeffrey E; Lee, Jeffrey E; Mansfield, Paul F; Lucci, Anthony; Cormier, Janice N

2009-06-01

The objectives of this analysis were to compare various measures associated with lymph node (LN) dissection and to identify threshold values associated with disease-specific survival (DSS) outcomes in patients with melanoma. Patients with lymph node-positive melanoma who underwent therapeutic LN dissection of the neck, axilla, and inguinal region were identified from the SEER database (1988-2005). We performed Cox multivariate analyses to determine the impact of the total number of LNs removed, number of negative LNs removed, and LN ratio on DSS. Multivariate cut-point analyses were conducted for each anatomic region to identify the threshold values associated with the largest improvement in DSS. The LN ratio was significantly associated with DSS for all LN regions. The LN ratio thresholds resulting in the greatest difference in 5-year DSS were .07, .13, and .18 for neck, axillary, and inguinal regions, respectively, corresponding to 15, 8, and 6 LNs removed per positive lymph node. After adjustment for other clinicopathologic factors, the hazard ratios (HRs) were .53 (95% confidence interval [CI], .40 to .71) in the neck, .52 (95% CI, .42 to .65) in the axillary, and .47 (95% CI, .36 to .61) in the inguinal regions for patients who met the LN ratio threshold. Among the prognostic factors examined, LN ratio was the best indicator of the extent of LN dissection, regardless of anatomic nodal region. These data provide evidence-based guidelines for defining adequate LN dissections in melanoma patients. (c) 2009 American Cancer Society.

Performance characteristics of prostate-specific antigen density and biopsy core details to predict oncological outcome in patients with intermediate to high-risk prostate cancer underwent robot-assisted radical prostatectomy.

PubMed

Yashi, Masahiro; Nukui, Akinori; Tokura, Yuumi; Takei, Kohei; Suzuki, Issei; Sakamoto, Kazumasa; Yuki, Hideo; Kambara, Tsunehito; Betsunoh, Hironori; Abe, Hideyuki; Fukabori, Yoshitatsu; Nakazato, Yoshimasa; Kaji, Yasushi; Kamai, Takao

2017-06-23

Many urologic surgeons refer to biopsy core details for decision making in cases of localized prostate cancer (PCa) to determine whether an extended resection and/or lymph node dissection should be performed. Furthermore, recent reports emphasize the predictive value of prostate-specific antigen density (PSAD) for further risk stratification, not only for low-risk PCa, but also for intermediate- and high-risk PCa. This study focused on these parameters and compared respective predictive impact on oncologic outcomes in Japanese PCa patients. Two-hundred and fifty patients with intermediate- and high-risk PCa according to the National Comprehensive Cancer Network (NCCN) classification, that underwent robot-assisted radical prostatectomy at a single institution, and with observation periods of longer than 6 months were enrolled. None of the patients received hormonal treatments including antiandrogens, luteinizing hormone-releasing hormone analogues, or 5-alpha reductase inhibitors preoperatively. PSAD and biopsy core details, including the percentage of positive cores and the maximum percentage of cancer extent in each positive core, were analyzed in association with unfavorable pathologic results of prostatectomy specimens, and further with biochemical recurrence. The cut-off values of potential predictive factors were set through receiver-operating characteristic curve analyses. In the entire cohort, a higher PSAD, the percentage of positive cores, and maximum percentage of cancer extent in each positive core were independently associated with advanced tumor stage ≥ pT3 and an increased index tumor volume > 0.718 ml. NCCN classification showed an association with a tumor stage ≥ pT3 and a Gleason score ≥8, and the attribution of biochemical recurrence was also sustained. In each NCCN risk group, these preoperative factors showed various associations with unfavorable pathological results. In the intermediate-risk group, the percentage of positive cores showed an independent predictive value for biochemical recurrence. In the high-risk group, PSAD showed an independent predictive value. PSAD and biopsy core details have different performance characteristics for the prediction of oncologic outcomes in each NCCN risk group. Despite the need for further confirmation of the results with a larger cohort and longer observation, these factors are important as preoperative predictors in addition to the NCCN classification for a urologic surgeon to choose a surgical strategy.

Combined robotic transanal total mesorectal excision (R-taTME) and single-site plus one-port (R-SSPO) technique for ultra-low rectal surgery-initial experience with a new operation approach.

PubMed

Kuo, Li-Jen; Ngu, James Chi-Yong; Tong, Yiu-Shun; Chen, Chia-Che

2017-02-01

Robot-assisted rectal surgery is gaining popularity, and robotic single-site surgery is also being explored clinically. We report our initial experience with robotic transanal total mesorectal excision (R-taTME) and radical proctectomy using the robotic single-site plus one-port (R-SSPO) technique for low rectal surgery. Between July 2015 and March 2016, 15 consecutive patients with ultra-low rectal lesions underwent R-taTME followed by radical proctectomy using the R-SSPO technique by a single surgeon. The clinical and pathological results were retrospectively analyzed. The median operative time was 473 (range, 335-569) min, and the estimated blood loss was 33 (range, 30-50) mL. The median number of lymph nodes harvested was 12 (range, 8-18). The median distal resection margin was 1.4 (range, 0.4-3.5) cm, and all patients had clear circumferential resection margins. We encountered a left ureteric transection intraoperatively in one patient, and another patient required reoperation for postoperative adhesive intestinal obstruction. There was no 30-day mortality. R-taTME followed by radical proctectomy using the R-SSPO technique for patients with low rectal lesions is technically feasible and safe without compromising oncologic outcomes. However, there were considerable limitations and a steep learning curve using current robotic technology.

OLDER ADULTS’ PREFERENCES FOR AND ACCEPTANCE OF ROBOT ASSISTANCE FOR EVERYDAY LIVING TASKS

PubMed Central

Smarr, Cory-Ann; Prakash, Akanksha; Beer, Jenay M.; Mitzner, Tracy L.; Kemp, Charles C.; Rogers, Wendy A.

2014-01-01

Many older adults value their independence and prefer to age in place. Robots can be designed to assist older people with performing everyday living tasks and maintaining their independence at home. Yet, there is a scarcity of knowledge regarding older adults’ attitudes toward robots and their preferences for robot assistance. Twenty-one older adults (M = 80.25 years old, SD = 7.19) completed questionnaires and participated in structured group interviews investigating their openness to and preferences for assistance from a mobile manipulator robot. Although the older adults were generally open to robot assistance for performing home-based tasks, they were selective in their views. Older adults preferred robot assistance over human assistance for many instrumental (e.g., housekeeping, laundry, medication reminders) and enhanced activities of daily living (e.g., new learning, hobbies). However, older adults were less open to robot assistance for some activities of daily living (e.g., shaving, hair care). Results from this study provide insight into older adults’ attitudes toward robot assistance with home-based everyday living tasks. PMID:25284971

Domestic Robots for Older Adults: Attitudes, Preferences, and Potential

PubMed Central

Mitzner, Tracy L.; Beer, Jenay M.; Prakash, Akanksha; Chen, Tiffany L.; Kemp, Charles C.; Rogers, Wendy A.

2014-01-01

The population of older adults in America is expected to reach an unprecedented level in the near future. Some of them have difficulties with performing daily tasks and caregivers may not be able to match pace with the increasing need for assistance. Robots, especially mobile manipulators, have the potential for assisting older adults with daily tasks enabling them to live independently in their homes. However, little is known about their views of robot assistance in the home. Twenty-one independently living older Americans (65–93 years old) were asked about their preferences for and attitudes toward robot assistance via a structured group interview and questionnaires. In the group interview, they generated a diverse set of 121 tasks they would want a robot to assist them with in their homes. These data, along with their questionnaire responses, suggest that the older adults were generally open to robot assistance but were discriminating in their acceptance of assistance for different tasks. They preferred robot assistance over human assistance for tasks related to chores, manipulating objects, and information management. In contrast, they preferred human assistance to robot assistance for tasks related to personal care and leisure activities. Our study provides insights into older adults' attitudes and preferences for robot assistance with everyday living tasks in the home which may inform the design of robots that will be more likely accepted by older adults. PMID:25152779

Domestic Robots for Older Adults: Attitudes, Preferences, and Potential.

PubMed

Smarr, Cory-Ann; Mitzner, Tracy L; Beer, Jenay M; Prakash, Akanksha; Chen, Tiffany L; Kemp, Charles C; Rogers, Wendy A

2014-04-01

The population of older adults in America is expected to reach an unprecedented level in the near future. Some of them have difficulties with performing daily tasks and caregivers may not be able to match pace with the increasing need for assistance. Robots, especially mobile manipulators, have the potential for assisting older adults with daily tasks enabling them to live independently in their homes. However, little is known about their views of robot assistance in the home. Twenty-one independently living older Americans (65-93 years old) were asked about their preferences for and attitudes toward robot assistance via a structured group interview and questionnaires. In the group interview, they generated a diverse set of 121 tasks they would want a robot to assist them with in their homes. These data, along with their questionnaire responses, suggest that the older adults were generally open to robot assistance but were discriminating in their acceptance of assistance for different tasks. They preferred robot assistance over human assistance for tasks related to chores, manipulating objects, and information management. In contrast, they preferred human assistance to robot assistance for tasks related to personal care and leisure activities. Our study provides insights into older adults' attitudes and preferences for robot assistance with everyday living tasks in the home which may inform the design of robots that will be more likely accepted by older adults.

The role of telementoring and telerobotic assistance in the provision of laparoscopic colorectal surgery in rural areas.

PubMed

Sebajang, H; Trudeau, P; Dougall, A; Hegge, S; McKinley, C; Anvari, M

2006-09-01

The aim of this study was to assess whether telementoring and telerobotic assistance would improve the range and quality of laparoscopic colorectal surgery being performed by community surgeons. We present a series of 18 patients who underwent telementored or telerobotically assisted laparoscopic colorectal surgery in two community hospitals between December 2002 and December 2003. Four community surgeons with no formal advanced laparoscopic fellowship were remotely mentored and assisted by an expert surgeon from a tertiary care center. Telementoring was achieved with real-time two-way audio-video communications over bandwidths of 384 kbps-1.2 mbps and included one redo ileocolic resection, two right hemicolectomies, two sigmoid resections, three low anterior resections, one subtotal colectomy, one reversal of a Hartmann operation, and one abdominoperineal resection. A Zeus TS microjoint system (Computer Motion Inc, Santa Barbara CA) was used to provide telepresence for the telerobotically assisted laparoscopic procedures, which included three right hemicolectomies, three sigmoid resections, and one low anterior resection. There were no major intraoperative complications. There were two minor intraoperative complications involving serosal tears of the colon from the robotic graspers. In the telementored cases, there were two postoperative complications requiring reoperation (intra-abdominal bleeding and small bowel obstruction). Two telementored procedures were converted because of the mentee's inability to find the appropriate planes of dissection. One telerobotically assisted procedure was completed laparoscopically by the local surgeon with aid of telementoring because of inadequate robotic arm position. The median length of hospital stay for this series was 4 days. The surgeons considered telementoring useful in all cases (median score 4 out of 5). The use of remote telerobotic assistance was also considered a significant enabling tool. Telementoring and remote telerobotic assistance are excellent tools for supporting community surgeons and providing patients better access to advanced surgical care.

[Exclusive use of blue dye to detect sentinel lymph nodes in breast cancer].

PubMed

Bühler H, Simón; Rojas P, Hugo; Cayazzo M, Daniela; Cunill C, Eduardo; Vesperinas A, Gonzalo; Hamilton S, James

2008-08-01

The use of a dye and radiocolloid to detect sentinel lymph nodes in breast cancer increases the detection rates. However the use of either method alone does not modify the false negative rate. Therefore there is no formal contraindication for the exclusive use of dye to detect nodes. To report a prospective analysis of the exclusive blue dye technique for sentinel node biopsy in patients with early breast cancer. We analyzed the first 100 women with pathologically proven breast cancer who met the inclusion criteria. Patent blue dye was used as colorant. In the first 25 cases sentinel node was identified using radiocolloid and blue dye an then an axillary dissection performed. In the next 25 women, blue dye was used exclusively for detection and an axillary dissection was performed. In the next 50 cases, blue dye was used and only isolated sentinel node biopsy was performed. In 92 of the 100 women a sentinel node was successfully detected. In the first 50 women, the false negative rate of sentinel lymph node detection was 6.9%. No complications occurred. During follow-up, lasting three to 29 months, no axillary relapse was observed. Sentinel node biopsy in patients with early breast cancer using exclusively blue dye is feasible and safe.

Promoting Interactions Between Humans and Robots Using Robotic Emotional Behavior.

PubMed

Ficocelli, Maurizio; Terao, Junichi; Nejat, Goldie

2016-12-01

The objective of a socially assistive robot is to create a close and effective interaction with a human user for the purpose of giving assistance. In particular, the social interaction, guidance, and support that a socially assistive robot can provide a person can be very beneficial to patient-centered care. However, there are a number of research issues that need to be addressed in order to design such robots. This paper focuses on developing effective emotion-based assistive behavior for a socially assistive robot intended for natural human-robot interaction (HRI) scenarios with explicit social and assistive task functionalities. In particular, in this paper, a unique emotional behavior module is presented and implemented in a learning-based control architecture for assistive HRI. The module is utilized to determine the appropriate emotions of the robot to display, as motivated by the well-being of the person, during assistive task-driven interactions in order to elicit suitable actions from users to accomplish a given person-centered assistive task. A novel online updating technique is used in order to allow the emotional model to adapt to new people and scenarios. Experiments presented show the effectiveness of utilizing robotic emotional assistive behavior during HRI scenarios.

Fluorescence-enhanced robotic radical prostatectomy using real-time lymphangiography and tissue marking with percutaneous injection of unconjugated indocyanine green: the initial clinical experience in 50 patients.

PubMed

Manny, Ted B; Patel, Manish; Hemal, Ashok K

2014-06-01

Pilot studies have demonstrated the utility of indocyanine green (ICG) sentinel lymphadenectomy for prostate cancer. Prior work has used ICG with radiocontrast agents injected at a separate procedure and relied on assistant-controlled fluorescence systems, making the technique costly and cumbersome. To describe the initial optimization and feasibility of fluorescence-enhanced robotic radical prostatectomy (FERRP) using real-time injection of ICG for tissue marking and identification of sentinel lymphatic drainage visualized by a fully integrated surgeon-controlled system. Patients with clinically localized prostate cancer at a tertiary referral center were offered FERRP. Ten patients participated in a pilot arm in which ICG dosing and injection technique were optimized. Fifty consecutive patients then underwent FERRP. After development of the space of Retzius, 0.4 ml of a 2.5 mg/ml ICG solution were injected into each lobe of the prostate using a robotically guided percutaneous needle. After ICG was allowed to travel through the pelvic lymphatics, lymphadenectomy was performed from the endopelvic fascia to the aortic bifurcation. Parameters describing the time course of tissue fluorescence and pelvic lymphangiography were systematically recorded. Lymphatic packets containing fluorescent nodes were considered sentinel. Percutaneous, robotic-guided ICG injection proved superior to cystoscope or transrectal delivery. Tissue marking was achieved in all patients, positively identifying the prostate with uniform fluorescence relative to the obturator nerve, seminal vesicles, vas deferens, and neurovascular pedicles at a mean time of 10 min postinjection. Sentinel nodes were identified in 76% of patients at a mean time of 30 min postinjection and had 100% sensitivity, 75.4% specificity, 14.6% positive predictive value, and 100% negative predictive value for the detection of nodal metastasis. FERRP is safe, feasible, and allows for reliable prostate tissue marking and identification of sentinel lymphatic drainage in the majority of patients. ICG sentinel nodes are highly sensitive but relatively nonspecific for the detection of nodal metastasis. Copyright © 2013. Published by Elsevier B.V.

Robotic transverse colectomy for mid-transverse colon cancer: surgical techniques and oncologic outcomes.

PubMed

Jung, Kyung Uk; Park, Yoonah; Lee, Kang Young; Sohn, Seung-Kook

2015-06-01

Robot-assisted surgery for colon cancer has been reported in many studies, most of which worked on right and/or sigmoid colectomy. The aim of this study was to report our experience of robotic transverse colectomy with an intracorporeal anastomosis, provide details of the surgical technique, and present the theoretical benefits of the procedure. This is a retrospective review of prospectively collected data of robotic surgery for colorectal cancer performed by a single surgeon between May 2007 and February 2011. Out of 162 consecutive cases, we identified three robotic transverse colectomies, using a hand-sewn intracorporeal anastomosis. Two males and one female underwent transverse colectomies for malignant or premalignant disease. The mean docking time, time spent using the robot, and total operative time were 5, 268, and 307 min, respectively. There were no conversions to open or conventional laparoscopic technique. The mean length of specimen and number of lymph nodes retrieved were 14.1 cm and 6.7, respectively. One patient suffered from a wound seroma and recovered with conservative management. The mean hospital stay was 8.7 days. After a median follow-up of 72 months, there were no local or systemic recurrences. Robotic transverse colectomy seems to be a safe and feasible technique. It may minimize the necessity of mobilizing both colonic flexures, with facilitated intracorporeal hand-sewn anastomosis. However, further prospective studies with a larger number of patients are required to draw firm conclusions.

The role of assistive robotics in the lives of persons with disability.

PubMed

Brose, Steven W; Weber, Douglas J; Salatin, Ben A; Grindle, Garret G; Wang, Hongwu; Vazquez, Juan J; Cooper, Rory A

2010-06-01

Robotic assistive devices are used increasingly to improve the independence and quality of life of persons with disabilities. Devices as varied as robotic feeders, smart-powered wheelchairs, independent mobile robots, and socially assistive robots are becoming more clinically relevant. There is a growing importance for the rehabilitation professional to be aware of available systems and ongoing research efforts. The aim of this article is to describe the advances in assistive robotics that are relevant to professionals serving persons with disabilities. This review breaks down relevant advances into categories of Assistive Robotic Systems, User Interfaces and Control Systems, Sensory and Feedback Systems, and User Perspectives. An understanding of the direction that assistive robotics is taking is important for the clinician and researcher alike; this review is intended to address this need.

Robotic-Assisted Versus Laparoscopic Colectomy: Cost and Clinical Outcomes

PubMed Central

Davis, Bradley R.; Yoo, Andrew C.; Moore, Matt

2014-01-01

Background and Objectives: Laparoscopic colectomies, with and without robotic assistance, are performed to treat both benign and malignant colonic disease. This study compared clinical and economic outcomes for laparoscopic colectomy procedures with and without robotic assistance. Methods: Patients aged ≥18 years having primary inpatient laparoscopic colectomy procedures (cecectomy, right hemicolectomy, left hemicolectomy, and sigmoidectomy) identified by International Classification of Diseases, Ninth Edition procedure codes performed between 2009 and the second quarter of 2011 from the Premier Hospital Database were studied. Patients were matched to a control cohort using propensity scores for disease, comorbidities, and hospital characteristics and were matched 1:1 for specific colectomy procedure. The outcomes of interest were hospital cost of laparoscopic robotic-assisted colectomy compared with traditional laparoscopic colectomy, surgery time, adverse events, and length of stay. Results: Of 25 758 laparoscopic colectomies identified, 98% were performed without robotic assistance and 2% were performed with robotic assistance. After matching, 1066 patients remained, 533 in each group. Lengths of stay were not significantly different between the matched cohorts, nor were rates of major, minor, and/or surgical complications. Inpatient procedures with robotic assistance were significantly more costly than those without robotic assistance ($17 445 vs $15 448, P = .001). Operative times were significantly longer for robotic-assisted procedures (4.37 hours vs 3.34 hours, P < .001). Conclusion: Segmental colectomies can be performed safely by either laparoscopic or robotic-assisted methods. Increased per-case hospital costs for robotic-assisted procedures and prolonged operative times suggest that further investigation is warranted when considering robotic technology for routine laparoscopic colectomies. PMID:24960484

Robotic-assisted versus laparoscopic colectomy: cost and clinical outcomes.

PubMed

Davis, Bradley R; Yoo, Andrew C; Moore, Matt; Gunnarsson, Candace

2014-01-01

Laparoscopic colectomies, with and without robotic assistance, are performed to treat both benign and malignant colonic disease. This study compared clinical and economic outcomes for laparoscopic colectomy procedures with and without robotic assistance. Patients aged ≥18 years having primary inpatient laparoscopic colectomy procedures (cecectomy, right hemicolectomy, left hemicolectomy, and sigmoidectomy) identified by International Classification of Diseases, Ninth Edition procedure codes performed between 2009 and the second quarter of 2011 from the Premier Hospital Database were studied. Patients were matched to a control cohort using propensity scores for disease, comorbidities, and hospital characteristics and were matched 1:1 for specific colectomy procedure. The outcomes of interest were hospital cost of laparoscopic robotic-assisted colectomy compared with traditional laparoscopic colectomy, surgery time, adverse events, and length of stay. Of 25,758 laparoscopic colectomies identified, 98% were performed without robotic assistance and 2% were performed with robotic assistance. After matching, 1066 patients remained, 533 in each group. Lengths of stay were not significantly different between the matched cohorts, nor were rates of major, minor, and/or surgical complications. Inpatient procedures with robotic assistance were significantly more costly than those without robotic assistance ($17,445 vs $15,448, P = .001). Operative times were significantly longer for robotic-assisted procedures (4.37 hours vs 3.34 hours, P < .001). Segmental colectomies can be performed safely by either laparoscopic or robotic-assisted methods. Increased per-case hospital costs for robotic-assisted procedures and prolonged operative times suggest that further investigation is warranted when considering robotic technology for routine laparoscopic colectomies.

Robotic-assisted versus laparoscopic colorectal surgery: a meta-analysis of four randomized controlled trials

PubMed Central

2014-01-01

Background Robotic-assisted laparoscopy is popularly performed for colorectal disease. The objective of this meta-analysis was to compare the safety and efficacy of robotic-assisted colorectal surgery (RCS) and laparoscopic colorectal surgery (LCS) for colorectal disease based on randomized controlled trial studies. Methods Literature searches of electronic databases (Pubmed, Web of Science, and Cochrane Library) were performed to identify randomized controlled trial studies that compared the clinical or oncologic outcomes of RCS and LCS. This meta-analysis was performed using the Review Manager (RevMan) software (version 5.2) that is provided by the Cochrane Collaboration. The data used were mean differences and odds ratios for continuous and dichotomous variables, respectively. Fixed-effects or random-effects models were adopted according to heterogeneity. Results Four randomized controlled trial studies were identified for this meta-analysis. In total, 110 patients underwent RCS, and 116 patients underwent LCS. The results revealed that estimated blood losses (EBLs), conversion rates and times to the recovery of bowel function were significantly reduced following RCS compared with LCS. There were no significant differences in complication rates, lengths of hospital stays, proximal margins, distal margins or harvested lymph nodes between the two techniques. Conclusions RCS is a promising technique and is a safe and effective alternative to LCS for colorectal surgery. The advantages of RCS include reduced EBLs, lower conversion rates and shorter times to the recovery of bowel function. Further studies are required to define the financial effects of RCS and the effects of RCS on long-term oncologic outcomes. PMID:24767102

Cribriform adenocarcinoma of the tongue and minor salivary gland: transoral robotic surgical resection.

PubMed

Worrall, Douglas M; Brant, Jason A; Chai, Raymond L; Weinstein, Gregory S

2015-01-01

Cribriform adenocarcinoma of the tongue and minor salivary gland (CATMSG) is a rare, locally invasive, and poorly recognized tumor, typically occurring on the base of the tongue. This case report describes the previously unreported use of transoral robotic surgery (TORS) for the local resection of CATMSG in a novel location, the palatine tonsil, and leverages follow-up information to compare TORS to conventional surgical approaches. We performed transoral radical tonsillectomy, limited pharyngectomy, and base-of-tongue resection with staged left selective neck dissection. Tumor pathology revealed an infiltrating salivary gland carcinoma with perineural invasion and a histologically similar adenocarcinoma in 1 of 64 left neck lymph nodes. TORS was performed with no perioperative complications, and the patient was subsequently discharge on postoperative day 3 with a Dobhoff tube. Postoperatively, the Dobhoff tube was removed at 1 month, the patient was advanced to soft foods by mouth at 2 months, and 3-month positron emission tomography-computed tomography scan showed no evidence of distant metastases and evolving postsurgical changes in the left tonsillectomy bed. This case report highlights the use of TORS resection with minimal acute and long-term morbidity compared to conventional approaches for the resection of this rare, locally invasive salivary gland carcinoma in the palatine tonsil. © 2015 S. Karger AG, Basel.

German, Austrian and Swiss consensus conference on the diagnosis and local treatment of the axilla in breast cancer.

PubMed

Hoffmann, Jürgen; Souchon, Rainer; Lebeau, Annette; Öhlschlegel, Christian; Gruber, Günther; Rageth, Christoph; Weber, Walter; Harbeck, Nadia; Janni, Wolfgang; Kreipe, Hans; Fitzal, Florian; Resch, Alexandra; Bago-Horvath, Zsuzsanna; Peintinger, Florentia

2013-07-01

The German, Austrian and Swiss (D.A.CH) Societies of Senology gathered together in 2012 to address dwelling questions regarding axillary clearance in breast cancer patients. The Consensus Panel consisted of 14 members of these societies and included surgical oncologists, gynaecologists, pathologists and radiotherapists. With regard to omitting axillary lymph node dissection in sentinel lymph node macrometastases, the Panel consensually accepted this option for low-risk patients only. A simple majority voted against extending radiotherapy to the axilla after omitting axillary dissection in N1 disease. Consensus was yielded for the use of axillary ultrasound and prospective registers for such patients in the course of follow-up. The questions regarding neoadjuvant therapy and the timing of sentinel lymph node biopsy failed to yield consensus, yet both options (before or after) are possible in clinically node-negative disease. Copyright © 2013 Elsevier Ltd. All rights reserved.

Simultaneous laparoscopy-assisted low anterior resection and distal gastrectomy for synchronous carcinoma of rectum and stomach

PubMed Central

Zhu, Qian-Lin; Zheng, Min-Hua; Feng, Bo; Lu, Ai-Guo; Wang, Min-Liang; Li, Jian-Wen; Hu, Wei-Guo; Zang, Lu; Mao, Zhi-Hai; Dong, Feng; Ma, Jun-Jun; Zong, Ya-Ping

2008-01-01

Laparoscopic resection of rectal cancer or gastric cancer has been advocated for the benefits of a reduced morbidity, a shorter treatment time, and similar outcomes. However, simultaneous laparoscopy-assisted low anterior resection and distal gastrectomy for synchronous carcinoma of rectum and stomach are rarely documented in literature. Endoscopic examination revealed a synchronous carcinoma of rectum and stomach in a 55-year-old male patient with rectal bleeding and epigastric discomfort. He underwent a simultaneous laparoscopy-assisted low anterior resection and distal gastrectomy with regional lymph nodes dissected. The operation time was 270 min and the estimated blood loss was 120 mL. The patient required parenteral analgesia for less than 24 h. Flatus was passed on postoperative day 3, and a solid diet was resumed on postoperative day 7. He was discharged on postoperative day 13. With the advances in laparoscopic technology and experience, simultaneous resection is an attractive alternative to a synchronous gastrointestinal cancer. PMID:18528944

Kotov and Williams with SSRMS arm training session in Node 1 / Unity module

NASA Image and Video Library

2007-04-18

ISS014-E-19587 (17 April 2007) --- Cosmonaut Oleg V. Kotov (foreground), Expedition 15 flight engineer representing Russia's Federal Space Agency, and astronaut Sunita L. Williams, flight engineer, participate in a Space Station Remote Manipulator System (SSRMS) training session using the Robotic Onboard Trainer (ROBOT) simulator in the Unity node of the International Space Station.

Occurrence of lymph node metastasis in early-stage parotid gland cancer.

PubMed

Stenner, Markus; Molls, Christoph; Luers, Jan C; Beutner, Dirk; Klussmann, Jens P; Huettenbrink, Karl-Bernd

2012-02-01

Lymph node metastasis is one of the most important factors in therapy and prognosis for patients with parotid gland cancer. Nevertheless, the extent of the primary tumor resection and the necessity of a neck dissection still is a common issue. Since little is known about lymph node metastasis in early-stage parotid gland cancer, the purpose of the present study was to evaluate the occurrence of lymph node metastases in T1 and T2 carcinomas and its impact on local control and survival. We retrospectively analyzed 70 patients with early-stage (T1 and T2) primary parotid gland cancer. All patients were treated with parotidectomy and an ipsilateral neck dissection from 1987 to 2009. Clinicopathological and survival parameters were calculated. The median follow-up time was 51.7 months. A positive pathological lymph node stage (pN+) was found in 21.4% of patients with a significant correlation to the clinical lymph node stage (cN) (p = 0.061). There were no differences in the clinical and histopathological data between pN- and pN+ patients. In 73.3% of pN+ patients, the metastases were located intraparotideal. The incidence of occult metastases (pN+/cN-) was 17.2%. Of all patients with occult metastases, 30.0% had extraparotideal lymphatic spread. A positive lymph node stage significantly indicated a poorer 5-year overall as well as 5-year disease-free survival rate compared to pN- patients (p = 0.048; p = 0.011). We propose total parotidectomy in combination with at least a level II-III selective neck dissection in any case of early-stage parotid gland cancer.

The Hand-Assisted Laparoscopic Approach to Resection of Pancreatic Mucinous Cystic Neoplasms: An Underused Technique?

PubMed

Postlewait, Lauren M; Ethun, Cecilia G; McInnis, Mia R; Merchant, Nipun; Parikh, Alexander; Idrees, Kamran; Isom, Chelsea A; Hawkins, William; Fields, Ryan C; Strand, Matthew; Weber, Sharon M; Cho, Clifford S; Salem, Ahmed; Martin, Robert C G; Scoggins, Charles; Bentrem, David; Kim, Hong J; Carr, Jacquelyn; Ahmad, Syed; Abbott, Daniel; Wilson, Gregory C; Kooby, David A; Maithel, Shishir K

2018-01-01

Pancreatic mucinous cystic neoplasms (MCNs) are rare tumors typically of the distal pancreas that harbor malignant potential. Although resection is recommended, data are limited on optimal operative approaches to distal pancreatectomy for MCN. MCN resections (2000-2014; eight institutions) were included. Outcomes of minimally invasive and open MCN resections were compared. A total of 289 patients underwent distal pancreatectomy for MCN: 136(47%) minimally invasive and 153(53%) open. Minimally invasive procedures were associated with smaller MCN size (3.9 vs 6.8 cm; P = 0.001), lower operative blood loss (192 vs 392 mL; P = 0.001), and shorter hospital stay(5 vs 7 days; P = 0.001) compared with open. Despite higher American Society of Anesthesiologists class, hand-assisted (n = 46) had similar advantages as laparoscopic/robotic (n = 76). When comparing hand-assisted to open, although MCN size was slightly smaller (4.1 vs 6.8 cm; P = 0.001), specimen length, operative time, and nodal yield were identical. Similar to laparoscopic/robotic, hand-assisted had lower operative blood loss (161 vs 392 mL; P = 0.001) and shorter hospital stay (5 vs 7 days; P = 0.03) compared with open, without increased complications. Hand-assisted laparoscopic technique is a useful approach for MCN resection because specimen length, lymph node yield, operative time, and complication profiles are similar to open procedures, but it still offers the advantages of a minimally invasive approach. Hand-assisted laparoscopy should be considered as an alternative to open technique or as a successive step before converting from total laparoscopic to open distal pancreatectomy for MCN.

Cryo-Assisted Resection En Bloc, and Cryoablation In Situ, of Primary Breast Cancer Coupled With Intraoperative Ultrasound-Guided Tracer Injection: A Preliminary Clinical Study.

PubMed

Korpan, Nikolai N; Xu, Kecheng; Schwarzinger, Philipp; Watanabe, Masashi; Breitenecker, Gerhard; Patrick, Le Pivert

2018-01-01

The aim of the study was to perform cryosurgery on a primary breast tumor, coupled with simultaneous peritumoral and intratumoral tracer injection of a blue dye, to evaluate lymphatic mapping. We explored the ability of our strategy to prevent tumor cells, but not that of injected tracers, to migrate to the lymphovascular drainage during conventional resection of frozen breast malignancies. Seventeen patients aged 51 (14) years (mean [standard deviation]), presenting primary breast cancer with stage I to IV, were randomly selected and treated in The Rudolfinerhaus Private Clinic in Vienna, Austria, and included in this preliminary clinical study. Under intraoperative ultrasound, 14 patients underwent curative cryo-assisted tumor resection en bloc, coupled with peritumoral tracer injection, which consisted of complete tumor freezing and concomitant peritumor injection with a blue dye, before resection and sentinel lymph node dissection (group A). Group B consists of 3 patients previously refused any standard therapy and had palliative tumor cryoablation in situ combined with intratumoral tracer injection. The intraoperative ultrasound facilitated needle positioning and dye injection timing. In group A, the frozen site extruded the dye that was distributed through the unfrozen tumor, the breast tissue, and the resection cavity for 12 patients. One to 4 lymph nodes were stained for 10 of 14 patients. The resection margin was evaluable. Our intraoperative ultrasound-guided performance revealed the injection and migration of a blue dye during the frozen resection en bloc and cryoablation in situ of primary breast tumors. Sentinel lymph node mapping, pathological determination of the tumor, and resection margins were achievable. The study paves the way for intraoperative cryo-assisted therapeutic strategies for breast cancer.

Da Vinci robot-assisted system for thymectomy: experience of 55 patients in China.

PubMed

Jun, Yi; Hao, Li; Demin, Li; Guohua, Dong; Hua, Jing; Yi, Shen

2014-09-01

Da Vinci robot-assisted thymectomy has been used in the past several years in China, however, practical experience in performing this approach in China remains limited. Thus, the study aimed to evaluate the experience of da Vinci robot-assisted thymectomy in China. From June 2010 to December 2012, 55 patients with diseases of the thymus underwent thymectomy using the da Vinci surgical HD robotic system. The clinical data of the da Vinci robot-assisted thymectomies were compared with the data of video-assisted thoracoscopic thymectomies in the same period. All da Vinci robot operations were successful. This is a retrospective analysis which demonstrated that compared with video-assisted thoracoscopic thymectomy in the same period, the clinical outcomes of da Vinci robot-assisted thymectomy were not significantly different. The da Vinci robot-assisted thymectomy is a safe, minimally invasive, and convenient operation, and shows promise for general thoracic surgery in China. Copyright © 2014 John Wiley & Sons, Ltd.

[Results of an individualized surgical therapy of vulvar carcinoma from 1973-1993].

PubMed

Köhler, U; Schöne, M; Pawlowitsch, T

1997-01-01

From 1973 through 1993, the University of Leipzig Women's Hospital treated 285 patients with primary vulvar malignancies. Of these, 269 cases (94.3%) were squamous cell carcinomas. The patients age averaged 69 years (25-95 years). 232 women (81.4%) were older than 60 years. Only 20 women (7%) were younger than 50 years. During the given time period, 266 patients (93.3%) underwent primary surgery. Standard operative treatment, performed in 105 cases (39.5%), was radical vulvectomy and bilateral superficial inguinal lymph node dissection. Rather than en bloc resection (Butterfly method), separate incisions were used during node dissection. Only 3 patients (2.9%) experienced a relapse within the remaining skin bridge. Irradiation with a focal doses of ca. 50 Gy followed postoperative-adjuvant in those cases involving the inguinal lymph nodes. In contrast, 161 patients received largely individualized surgical treatment. Local tumor extension and patient age-dependent operability influenced the choice of treatment. Partial vulvectomy was performed in 37 cases (13.9%). Simple vulvectomy without inguinal node dissection was performed in 115 cases (43.2%) and 9 patients underwent vulvectomy with vaginal-, urethral- and partial sphincter resection, accompanied by myocutaneous flap transposition (M. gluteus maximus lobe). The cumulative (corrected) 5-year survival rate for all patients with squamous cell carcinoma was 68.6%. No significant relationship between patient age (> 60 years vs. < or = 60 years) and prognosis could be seen. Factors of importance to the prognosis, however, were primary tumor size (FIGO stage I vs. II vs. III/IV), principal tumor site (significantly poorer survival rates characterize both clitoral and multifocal carcinomas), histological staging (G1 vs. G2/G3), inguinal lymph node involvement (pN+ vs. pN-) and degree of tumor resection in "healthy" (> or = 2 cm vs. < 2 cm). 5-year survival rates among those patients receiving individualized operative care did not differ significantly. Patient survival rates were 70.3% by partial vulvectomy, 78.2% by simple vulvectomy without inguinal node dissection and 67.6% by radical vulvectomy and bilateral inguinal node dissection with or without postoperative-adjuvant irradiation. These findings, therefore, justify the individualized operative treatment of patients with vulvar carcinoma according to each patient's initial prognostic situation. The relatively seldom vulvar carcinoma should only be treated by experienced surgeons in an appropriate hospital environment. Moreover, assessment of histological sections must be standardized, reproducible and above all, include the very accurate evaluation of all resection edges.

Robotic Telesurgery Research

DTIC Science & Technology

2010-10-01

Miniature In Vivo Robotic System for the Surgical Treatment of Diverticular Disease Source of Support: National Institute of Health (NIH) Total...completion time   • Suturing   • Gastrotomy   • Partial colon resection   • Completion of a fully closed procedure - the robot was inserted...repositioned over the sigmoid colon in the left pelvis of the swine and was used, with one grasper hand and one cautery hand, to dissect out the mesentery of

Predictive factors for lymph node metastasis in poorly differentiated early gastric cancer and their impact on the surgical strategy

PubMed Central

Li, Hua; Lu, Ping; Lu, Yang; Liu, Cai-Gang; Xu, Hui-Mian; Wang, Shu-Bao; Chen, Jun-Qing

2008-01-01

AIM: To identify the predictive clinicopathological factors for lymph node metastasis (LNM) in poorly differentiated early gastric cancer (EGC) and to further expand the possibility of using endoscopic mucosal resection (EMR) for the treatment of poorly differentiated EGC. METHODS: Data were collected from 85 poorly-differentiated EGC patients who were surgically treated. Association between the clinicopathological factors and the presence of LNM was retrospectively analyzed by univariate and multivariate logistic regression analyses. RESULTS: Univariate analysis showed that tumor size (OR = 5.814, 95% CI = 1.050 - 32.172, P = 0.044), depth of invasion (OR = 10.763, 95% CI = 1.259 - 92.026, P = 0.030) and lymphatic vessel involvement (OR = 61.697, 95% CI = 2.144 - 175.485, P = 0.007) were the significant and independent risk factors for LNM. The LNM rate was 5.4%, 42.9% and 50%, respectively, in poorly differentiated EGC patients with one, two and three of the risk factors, respectively. No LNM was found in 25 patients without the three risk factors. Forty-four lymph nodes were found to have metastasis, 29 (65.9%) and 15 (34.1%) of the lymph nodes involved were within N1 and beyond N1, respectively, in 12 patients with LNM. CONCLUSION: Endoscopic mucosal resection alone may be sufficient to treat poorly differentiated intramucosal EGC (≤ 2.0 cm in diameter) with no histologically-confirmed lymphatic vessel involvement. When lymphatic vessels are involved, lymph node dissection beyond limited (D1) dissection or D1+ lymph node dissection should be performed depending on the tumor location. PMID:18636670

Tumour thickness as a determinant of nodal metastasis in oral tongue carcinoma.

PubMed

Wang, Kejia; Veivers, David

2017-09-01

Tumour thickness is a strong predictor for cervical node involvement in oral cavity squamous cell carcinomas (SCCs), with a recent meta-analysis concluding a 4-mm optimal prognostic cut-off point. No consensus has been reached for the tumour thickness cut-off for oral tongue SCCs. A retrospective review of prospectively collected data from 112 patients by the Northern Sydney Cancer Centre (Australia) with primary oral tongue SCC was conducted. Tumour thickness was measured by standard histopathological techniques and cervical node involvement was determined either from neck dissection histopathology or by clinical and radiological follow-up. Neck dissection was performed in 78 patients (70%). Tumour thickness was a significant predictor of cervical node disease (P < 0.01), with a median tumour thickness of 5.5 mm. Cervical node metastasis rates for tumours <2, 2-3.9 and ≥4 mm thick were 10%, 42.1% and 46.5%, respectively. The rate of cervical node metastasis was significantly higher for patients with tumours thicker than a cut-off of 2 mm (odds ratio: 7.53, P < 0.01). A 4-mm thickness cut-off was also statistically significant (P < 0.05); however, the odds ratio was smaller at 2.52. Despite some previous evidence for a 4-mm tumour thickness cut-off in oral tongue SCCs, thinner tumours (2-3.9 mm) can also have a propensity for cervical node metastasis. Patients in this category require close monitoring for regional recurrence if they do not have a neck dissection. © 2016 Royal Australasian College of Surgeons.

Robotic colorectal surgery: previous laparoscopic colorectal experience is not essential.

PubMed

Sian, Tanvir Singh; Tierney, G M; Park, H; Lund, J N; Speake, W J; Hurst, N G; Al Chalabi, H; Smith, K J; Tou, S

2018-06-01

A background in minimally invasive colorectal surgery (MICS) has been thought to be essential prior to robotic-assisted colorectal surgery (RACS). Our aim was to determine whether MICS is essential prior to starting RACS training based on results from our initial experience with RACS. Two surgeons from our centre received robotic training through the European Academy of Robotic Colorectal Surgery (EARCS). One surgeon had no prior formal MICS training. We reviewed the first 30 consecutive robotic colorectal procedures from a prospectively maintained database between November 2014 and January 2016 at our institution. Fourteen patients were male. Median age was 64.5 years (range 36-82) and BMI was 27.5 (range 20-32.5). Twelve procedures (40%) were performed by the non-MICS-trained surgeon: ten high anterior resections (one conversion), one low anterior resection and one abdomino-perineal resection of rectum (APER). The MICS-trained surgeon performed nine high and four low anterior resections, one APER and in addition three right hemicolectomies and one abdominal suture rectopexy. There were no intra-operative complications and two patients required re-operation. Median post-operative stay was five days (range 1-26). There were two 30-day re-admissions. All oncological resections had clear margins and median node harvest was 18 (range 9-39). Our case series demonstrates that a background in MICS is not essential prior to starting RACS training. Not having prior MICS training should not discourage surgeons from considering applying for a robotic training programme. Safe and successful robotic colorectal services can be established after completing a formal structured robotic training programme.

Performance Evaluation Methods for Assistive Robotic Technology

NASA Astrophysics Data System (ADS)

Tsui, Katherine M.; Feil-Seifer, David J.; Matarić, Maja J.; Yanco, Holly A.

Robots have been developed for several assistive technology domains, including intervention for Autism Spectrum Disorders, eldercare, and post-stroke rehabilitation. Assistive robots have also been used to promote independent living through the use of devices such as intelligent wheelchairs, assistive robotic arms, and external limb prostheses. Work in the broad field of assistive robotic technology can be divided into two major research phases: technology development, in which new devices, software, and interfaces are created; and clinical, in which assistive technology is applied to a given end-user population. Moving from technology development towards clinical applications is a significant challenge. Developing performance metrics for assistive robots poses a related set of challenges. In this paper, we survey several areas of assistive robotic technology in order to derive and demonstrate domain-specific means for evaluating the performance of such systems. We also present two case studies of applied performance measures and a discussion regarding the ubiquity of functional performance measures across the sampled domains. Finally, we present guidelines for incorporating human performance metrics into end-user evaluations of assistive robotic technologies.

Human-Robot Interaction: Does Robotic Guidance Force Affect Gait-Related Brain Dynamics during Robot-Assisted Treadmill Walking?

PubMed

Knaepen, Kristel; Mierau, Andreas; Swinnen, Eva; Fernandez Tellez, Helio; Michielsen, Marc; Kerckhofs, Eric; Lefeber, Dirk; Meeusen, Romain

2015-01-01

In order to determine optimal training parameters for robot-assisted treadmill walking, it is essential to understand how a robotic device interacts with its wearer, and thus, how parameter settings of the device affect locomotor control. The aim of this study was to assess the effect of different levels of guidance force during robot-assisted treadmill walking on cortical activity. Eighteen healthy subjects walked at 2 km.h-1 on a treadmill with and without assistance of the Lokomat robotic gait orthosis. Event-related spectral perturbations and changes in power spectral density were investigated during unassisted treadmill walking as well as during robot-assisted treadmill walking at 30%, 60% and 100% guidance force (with 0% body weight support). Clustering of independent components revealed three clusters of activity in the sensorimotor cortex during treadmill walking and robot-assisted treadmill walking in healthy subjects. These clusters demonstrated gait-related spectral modulations in the mu, beta and low gamma bands over the sensorimotor cortex related to specific phases of the gait cycle. Moreover, mu and beta rhythms were suppressed in the right primary sensory cortex during treadmill walking compared to robot-assisted treadmill walking with 100% guidance force, indicating significantly larger involvement of the sensorimotor area during treadmill walking compared to robot-assisted treadmill walking. Only marginal differences in the spectral power of the mu, beta and low gamma bands could be identified between robot-assisted treadmill walking with different levels of guidance force. From these results it can be concluded that a high level of guidance force (i.e., 100% guidance force) and thus a less active participation during locomotion should be avoided during robot-assisted treadmill walking. This will optimize the involvement of the sensorimotor cortex which is known to be crucial for motor learning.

Many Men with Penile Cancer Not Getting Recommended Treatments

Cancer.gov

Professional guidelines recommend that men with penile cancer that has not spread beyond nearby lymph nodes undergo lymph node dissection and receive chemotherapy. As this Cancer Currents blog post reports, that’s not happening for many men.

Mediastinal micro-vessels clipping during lymph node dissection may contribute to reduce postoperative pleural drainage

PubMed Central

Yan, Shi; Wang, Xing; Lv, Chao; Phan, Kevin; Wang, Yuzhao; Wang, Jia; Yang, Yue

2016-01-01

Background Postoperative pleural drainage markedly influences the length of postoperative stay and financial costs of medical care. The aim of this study is to retrospectively investigate potentially predisposing factors related to pleural drainage after curative thoracic surgery and to explore the impact of mediastinal micro-vessels clipping on pleural drainage control after lymph node dissection. Methods From February 2012 to November 2013, 322 consecutive cases of operable non-small cell lung cancers (NSCLC) undergoing lobectomy and mediastinal lymph node dissection with or without application of clipping were collected. Total and daily postoperative pleural drainage were recorded. Propensity score matching (1:2) was applied to balance variables potentially impacting pleural drainage between group clip and group control. Analyses were performed to compare drainage volume, duration of chest tube and postoperative hospital stay between the two groups. Variables linked with pleural drainage in whole cohort were assessed using multivariable logistic regression analysis. Results Propensity score matching resulted in 197 patients (matched cohort). Baseline patient characteristics were matched between two groups. Group clip showed less cumulative drainage volume (P=0.020), shorter duration of chest tube (P=0.031) and postoperative hospital stay (P=0.022) compared with group control. Risk factors significantly associated with high-output drainage in multivariable logistic regression analysis were being male, age >60 years, bilobectomy/sleeve lobectomy, pleural adhesion, the application of clip applier, duration of operation ≥220 minutes and chylothorax (P<0.05). Conclusions This study suggests that mediastinal micro-vessels clipping during lymph node dissection may reduce postoperative pleural drainage and thus shorten hospital stay. PMID:27076936

Simplified intraoperative sentinel-node detection performed by the urologist accurately determines lymph-node stage in prostate cancer.

PubMed

Kjölhede, Henrik; Bratt, Ola; Gudjonsson, Sigurdur; Sundqvist, Pernilla; Liedberg, Fredrik

2015-04-01

The reference standard for lymph-node staging in prostate cancer is currently an extended pelvic lymph-node dissection (ePLND), which detects most, but not all, regional lymph-node metastases. As an alternative to ePLND, sentinel-node dissection with preoperative isotope injection and imaging has been reported. The objective was to determine whether intraoperative sentinel-node detection with a simplified protocol can accurately determine lymph-node stage in prostate cancer patients. Patients with biopsy-verified high-risk prostate cancer with tumour stage T2-3 were included in the study. All patients underwent both ePLND and sentinel-node detection. (99m)Tc-marked nanocolloid was injected peritumourally by the operating urologist after induction of anaesthesia just before surgery. Sentinel nodes were detected both in vivo and ex vivo intraoperatively using a gamma probe. Sentinel nodes and metastases and their locations were recorded. Sensitivity and specificity were calculated. At least one sentinel node was detected in 72 (87%) of the 83 patients. In 13 (18%) of these 72 patients sentinel nodes were detected outside the ePLND template. In six of these 13 patients, the Sentinel nodes from outside the template contained metastases, which proved to be the only metastases in two. For 12 patients the only metastatic deposit found was a micrometastasis (≤2 mm) in a sentinel node. In the 72 patients with detectable sentinel nodes, pathological analysis of the sentinel node correctly categorized 71 and ePLND 70 patients. This protocol yielded results comparable to the commonly used technique of sentinel-node detection, but with more cases of non-detection.

Extended lymphadenectomy in bladder cancer.

PubMed

Dorin, Ryan P; Skinner, Eila C

2010-09-01

Radical cystectomy with pelvic lymph node dissection (PLND) is the preferred treatment for invasive bladder cancer. It not only results in the best disease-free term survival rates, but also provides the most accurate disease staging and most effective local symptom control. Recent investigations have demonstrated a clinical benefit to performance of an extended PLND, including all lymphatic tissue to the level of the aortic bifurcation. This review will summarize recent findings regarding the clinical benefits of radical cystectomy with extended lymphadenectomy, and will also examine the latest surgical techniques for optimizing the performance of this technically demanding procedure. Recent studies have demonstrated increased recurrence-free survival and overall survival rates in patients undergoing radical cystectomy with extended PLND, even in cases of pathologically lymph node negative disease. The growing use of minimally invasive techniques has prompted interest in robotic radical cystectomy and extended PLND, and recent reports have demonstrated the feasibility of this technique. The standardization of extended PLND templates has also been a focus of contemporary research. Contemporary research strongly suggests that all patients undergoing radical cystectomy for bladder cancer should undergo concomitant extended PLND. Randomized trials are still needed to confirm the benefits of extended over 'standard' PLND, and to clarify which patients may receive the greatest benefit from this procedure.

Isolated perifacial lymph node metastasis in oral squamous cell carcinoma with clinically node-negative neck.

PubMed

Agarwal, Sangeet Kumar; Arora, Sowrabh Kumar; Kumar, Gopal; Sarin, Deepak

2016-10-01

The incidence of occult perifacial nodal disease in oral cavity squamous cell carcinoma is not well reported. The purpose of this study was to evaluate the incidence of isolated perifacial lymph node metastasis in patients with oral squamous cell carcinoma with a clinically node-negative neck. The study will shed light on current controversies and will provide valuable clinical and pathological information in the practice of routine comprehensive removal of these lymph node pads in selective neck dissection in the node-negative neck. Prospective analysis. This study was started in August 2011 when intraoperatively we routinely separated the lymph node levels from the main specimen for evaluation of the metastatic rate to different lymph node levels in 231 patients of oral squamous cell cancer with a clinically node-negative neck. The current study demonstrated that 19 (8.22%) out of 231 patients showed ipsilateral isolated perifacial lymph node involvement. The incidence of isolated perifacial nodes did not differ significantly between the oral tongue (7.14%) and buccal mucosa (7.75%). Incidence was statistically significant in cases with lower age group (<45 years), advanced T stage, and higher depth of tumor invasion. Isolated perifacial node metastasis is high in oral squamous cell carcinoma with a clinically node-negative neck. The incidence of isolated perifacial involvement is high in cases of buccal mucosal and tongue cancers. A meticulous dissection of the perifacial nodes seems prudent when treating the neck in oral cavity squamous cell carcinoma. 4 Laryngoscope, 126:2252-2256, 2016. © 2016 The American Laryngological, Rhinological and Otological Society, Inc.

Wrist Rehabilitation Assisted by an Electromyography-Driven Neuromuscular Electrical Stimulation Robot After Stroke.

PubMed

Hu, Xiao-Ling; Tong, Raymond Kai-yu; Ho, Newmen S K; Xue, Jing-jing; Rong, Wei; Li, Leonard S W

2015-09-01

Augmented physical training with assistance from robot and neuromuscular electrical stimulation (NMES) may introduce intensive motor improvement in chronic stroke. To compare the rehabilitation effectiveness achieved by NMES robot-assisted wrist training and that by robot-assisted training. This study was a single-blinded randomized controlled trial with a 3-month follow-up. Twenty-six hemiplegic subjects with chronic stroke were randomly assigned to receive 20-session wrist training with an electromyography (EMG)-driven NMES robot (NMES robot group, n = 11) and with an EMG-driven robot (robot group, n = 15), completed within 7 consecutive weeks. Clinical scores, Fugl-Meyer Assessment (FMA), Modified Ashworth Score (MAS), and Action Research Arm Test (ARAT) were used to evaluate the training effects before and after the training, as well as 3 months later. An EMG parameter, muscle co-contraction index, was also applied to investigate the session-by-session variation in muscular coordination patterns during the training. The improvement in FMA (shoulder/elbow, wrist/hand) obtained in the NMES robot group was more significant than the robot group (P < .05). Significant improvement in ARAT was achieved in the NMES robot group (P < .05) but absent in the robot group. NMES robot-assisted training showed better performance in releasing muscle co-contraction than the robot-assisted across the training sessions (P < .05). The NMES robot-assisted wrist training was more effective than the pure robot. The additional NMES application in the treatment could bring more improvements in the distal motor functions and faster rehabilitation progress. © The Author(s) 2014.

Three-dimensional simulation, surgical navigation and thoracoscopic lung resection

PubMed Central

Kanzaki, Masato; Kikkawa, Takuma; Sakamoto, Kei; Maeda, Hideyuki; Wachi, Naoko; Komine, Hiroshi; Oyama, Kunihiro; Murasugi, Masahide; Onuki, Takamasa

2013-01-01

This report describes a 3-dimensional (3-D) video-assisted thoracoscopic lung resection guided by a 3-D video navigation system having a patient-specific 3-D reconstructed pulmonary model obtained by preoperative simulation. A 78-year-old man was found to have a small solitary pulmonary nodule in the left upper lobe in chest computed tomography. By a virtual 3-D pulmonary model the tumor was found to be involved in two subsegments (S1 + 2c and S3a). Complete video-assisted thoracoscopic surgery bi-subsegmentectomy was selected in simulation and was performed with lymph node dissection. A 3-D digital vision system was used for 3-D thoracoscopic performance. Wearing 3-D glasses, the patient's actual reconstructed 3-D model on 3-D liquid-crystal displays was observed, and the 3-D intraoperative field and the picture of 3-D reconstructed pulmonary model were compared. PMID:24964426

Assistant Personal Robot (APR): Conception and Application of a Tele-Operated Assisted Living Robot.

PubMed

Clotet, Eduard; Martínez, Dani; Moreno, Javier; Tresanchez, Marcel; Palacín, Jordi

2016-04-28

This paper presents the technical description, mechanical design, electronic components, software implementation and possible applications of a tele-operated mobile robot designed as an assisted living tool. This robotic concept has been named Assistant Personal Robot (or APR for short) and has been designed as a remotely telecontrolled robotic platform built to provide social and assistive services to elderly people and those with impaired mobility. The APR features a fast high-mobility motion system adapted for tele-operation in plain indoor areas, which incorporates a high-priority collision avoidance procedure. This paper presents the mechanical architecture, electrical fundaments and software implementation required in order to develop the main functionalities of an assistive robot. The APR uses a tablet in order to implement the basic peer-to-peer videoconference and tele-operation control combined with a tactile graphic user interface. The paper also presents the development of some applications proposed in the framework of an assisted living robot.

Efficacy of Superselective Neck Dissection in Detecting Metastasis in Patients with cN0 Papillary Thyroid Carcinoma at High Risk of Lateral Neck Metastasis

PubMed Central

An, Changming; Zhang, Xiwei; Wang, Shixu; Zhang, Zongmin; Yin, Yulin; Xu, Zhengang; Tang, Pingzhang; Li, Zhengjiang

2017-01-01

Background This study aimed to evaluate superselective neck dissection (SSND) in patients with cN0 papillary thyroid carcinoma (PTC) at high risk of lateral cervical lymph node (LN) metastasis. Material/Methods This study enrolled 138 patients with PTC who underwent SSND. These patients were at high risk for LN metastasis and the rate of cervical LN metastasis was recorded. Results In all, 146 lateral neck dissections were performed in 138 patients. Intraoperative pathological data revealed LN metastasis from 55 cases, for which Level II and V dissection were performed. Ninety SSNDs were performed in the other 83 patients without metastasis identified in frozen sections. Occult lymph node metastasis (OLNM) rates were 56.8% and 43.5% in the central compartment and lateral neck, respectively. OLNM rates of Level II–VI were 17.8%, 31.5%, 36.3%, 1.4%, and 56.8%, respectively. Level VI metastasis (p<0.001), extra thyroidal extension (p=0.003), and tumor size (p=0.011) were significant factors for lateral neck LN metastasis. Conclusions SSND might be effective for early diagnosis of lateral neck metastases of PTC. Patients with OLNM should receive level II, III, and IV dissection, but level V dissection could be omitted. PMID:28469126

[The historical perspective of the sentinel lymph node concept].

PubMed

Bekker, J; Meijer, S

2008-01-05

The sentinel lymph node procedure is currently standard care in the treatment of breast cancer. The introduction of this procedure in 1992 would not have been possible without the pioneering discoveries regarding lymph nodes and cancer. The Italian surgeon Gaspar Asellius (1581-1626) visualized the lymphatic vessels of a dog after it had been fed and shortly before dissection. At the end of the 17th century, the French anatomists Lauth and Sappey visualized the lymphatics by injecting deceased criminals with mercury. In 1858, the German pathologist Virchow (1821-1902) launched the theory that lymph nodes act as defensive barriers. He also made the first microscopical illustration ofa sentinel lymph node. Gould et al. and Cabaãs independently launched the precursors of the current modern sentinel lymph node concept in 1959 and 1977 respectively. Gould et al. were the first people to use the term "sentinel node'. Cabañas used lymphangiography for the visualisation of the sentinel lymph node. Controversies about the barrier function of the lymph nodes, the fear of skip metastasis and the difficulties of performing the Cabañas procedure, prevented a breakthrough of this concept. In 1992 Morton et al. rediscovered the valuable sentinel node biopsy concept and introduced blue dye for the investigation of patients with melanoma. The combination of lymphoscintigraphy, intra-operative gamma probe guidance and patent blue further increased the reliability of the sentinel lymph node biopsy procedure. Unnecessary lymph gland dissection procedures with considerable morbidity can be prevented by this procedure.

Validation of the da Vinci Surgical Skill Simulator across three surgical disciplines: A pilot study

PubMed Central

Alzahrani, Tarek; Haddad, Richard; Alkhayal, Abdullah; Delisle, Josée; Drudi, Laura; Gotlieb, Walter; Fraser, Shannon; Bergman, Simon; Bladou, Frank; Andonian, Sero; Anidjar, Maurice

2013-01-01

Objective: In this paper, we evaluate face, content and construct validity of the da Vinci Surgical Skills Simulator (dVSSS) across 3 surgical disciplines. Methods: In total, 48 participants from urology, gynecology and general surgery participated in the study as novices (0 robotic cases performed), intermediates (1–74) or experts (≥75). Each participant completed 9 tasks (Peg board level 2, match board level 2, needle targeting, ring and rail level 2, dots and needles level 1, suture sponge level 2, energy dissection level 1, ring walk level 3 and tubes). The Mimic Technologies software scored each task from 0 (worst) to 100 (best) using several predetermined metrics. Face and content validity were evaluated by a questionnaire administered after task completion. Wilcoxon test was used to perform pair wise comparisons. Results: The expert group comprised of 6 attending surgeons. The intermediate group included 4 attending surgeons, 3 fellows and 5 residents. The novices included 1 attending surgeon, 1 fellow, 13 residents, 13 medical students and 2 research assistants. The median number of robotic cases performed by experts and intermediates were 250 and 9, respectively. The median overall realistic score (face validity) was 8/10. Experts rated the usefulness of the simulator as a training tool for residents (content validity) as 8.5/10. For construct validity, experts outperformed novices in all 9 tasks (p < 0.05). Intermediates outperformed novices in 7 of 9 tasks (p < 0.05); there were no significant differences in the energy dissection and ring walk tasks. Finally, experts scored significantly better than intermediates in only 3 of 9 tasks (matchboard, dots and needles and energy dissection) (p < 0.05). Conclusions: This study confirms the face, content and construct validities of the dVSSS across urology, gynecology and general surgery. Larger sample size and more complex tasks are needed to further differentiate intermediates from experts. PMID:23914275

Technical mentorship during robot-assisted surgery: a cognitive analysis.

PubMed

Hussein, Ahmed A; Shafiei, Somayeh B; Sharif, Mohamed; Esfahani, Ehsan; Ahmad, Basel; Kozlowski, Justen D; Hashmi, Zishan; Guru, Khurshid A

2016-09-01

To investigate cognitive and mental workload assessments, which may play a critical role in defining successful mentorship. The 'Mind Maps' project aimed at evaluating cognitive function with regard to surgeon's expertise and trainee's skills. The study included electroencephalogram (EEG) recordings of a mentor observing trainee surgeons in 20 procedures involving extended lymph node dissection (eLND) or urethrovesical anastomosis (UVA), with simultaneous assessment of trainees using the National Aeronautics and Space Administration Task Load index (NASA-TLX) questionnaire. We also compared the brain activity of the mentor during this study with his own brain activity while actually performing the same surgical steps from previous procedures populated in the 'Mind Maps' project. During eLND and UVA, when the mentor thought the trainee's mental demand and effort were low based on his NASA-TLX questionnaire (not satisfied with his performance), his EEG-based mental workload increased (reflecting more concern and attention). The mentor was mentally engaged and concerned while he was engrossed in observing the surgery. This was further supported by the finding that there was no significant difference in the mental demands and workload between observing and operating for the expert surgeon. This study objectively evaluated the cognitive engagement of a surgical mentor teaching technical skills during surgery. The study provides a deeper understanding of how surgical teaching actually works and opens new horizons for assessment and teaching of surgery. Further research is needed to study the feasibility of this novel concept in assessment and guidance of surgical performance. © 2016 The Authors BJU International © 2016 BJU International Published by John Wiley & Sons Ltd.

National trends and differences in morbidity among surgical approaches for radical prostatectomy in Germany.

PubMed

Stolzenburg, Jens Uwe; Kyriazis, Iason; Fahlenbrach, Claus; Gilfrich, Christian; Günster, Christian; Jeschke, Elke; Popken, Gralf; Weißbach, Lothar; von Zastrow, Christoph; Leicht, Hanna

2016-11-01

In this study, we document trends in radical prostatectomy (RP) employment in Germany during the period 2005-2012 and compare the morbidity of open (ORP), laparoscopic and robotic-assisted RP based on nationwide administrative data of Allgemeine Ortskrankenkassen (AOK) German local healthcare funds. Administrative claims data of all AOK patients subjected to RP during 2005-2012 (57,156 cases) were used to evaluate the employment of minimally invasive RP (MIRP) procedures, pelvic lymph node dissection (PLND) and nerve-sparing approaches during this period. In addition, data from the most recent three-year period of our dataset (2010-2012) were used to compare the morbidity among the different surgical approaches. Study end points comprised 30-day mortality, 30-day transfusion, 1-year reintervention and 30-day adverse events, as well as 1-year overall complications. A 20 % reduction in RP utilization from 2007 to 2012 was documented. ORP remained the predominant RP approach in Germany. MIRP approaches carried a lower risk of 30-day transfusions, 1-year reinterventions and 1-year overall complications than ORP when adjusting for confounding factors. PLND was associated with an increased risk of complications, while age in the highest quintile and the presence of comorbidities were independent risk factors for morbidity and mortality. Lack of pathological data was the main limitation of the study. RP utilization in Germany is dropping, but the use of MIRP has risen steadily during the years 2005-2012, which is expected to have a positive impact on the morbidity of the operation.

3D vision improves outcomes in early cervical cancer treated with laparoscopic type B radical hysterectomy and pelvic lymphadenectomy.

PubMed

Raspagliesi, Francesco; Bogani, Giorgio; Martinelli, Fabio; Signorelli, Mauro; Scaffa, Cono; Sabatucci, Ilaria; Lorusso, Domenica; Ditto, Antonino

2017-01-21

To evaluate the alterations on surgical outcomes after of the implementation of 3D laparoscopic technology for the surgical treatment of early-stage cervical carcinoma. Data of patients undergoing type B radical hysterectomy (with or without bilateral salpingo-oophorectomy) and pelvic lymphadenectomy via 3D laparoscopy were compared with a historical cohort of patients undergoing type B radical hysterectomy via conventional laparoscopy. Complications (within 60 days) were graded per the Accordion severity system. Data of 75 patients were studied: 15 (20%) and 60 (80%) patients undergoing surgery via 3D laparoscopy and conventional laparoscopy, respectively. Baseline patient characteristics as well as pathologic findings were similar between groups (p>0.1). Patients undergoing 3D laparoscopy experienced a trend toward shorter operative time than patients undergoing conventional laparoscopy (176.7 ± 74.6 vs 215.9 ± 61.6 minutes; p = 0.09). Similarly, patients undergoing 3D laparoscopic radical hysterectomy experienced shorter length of hospital stay (2 days, range 2-6, vs 4 days, range 3-11; p<0.001) in comparison to patients in the control group, while no difference in estimated blood loss was observed (p = 0.88). No between-group difference in complication rate was observed. 3D technology is a safe and effective way to perform type B radical hysterectomy and pelvic node dissection in early-stage cervical cancer. Further large prospective studies are warranted in order to assess the cost-effectiveness of the introduction of 3D technology in comparison to robotic assisted surgery.

Robotic surgery twice performed in the treatment of hilar cholangiocarcinoma with deep jaundice: delayed right hemihepatectomy following the right-hepatic vascular control.

PubMed

Zhu, Zhenyu; Liu, Quanda; Chen, Junzhou; Duan, Weihong; Dong, Maosheng; Mu, Peiyuan; Cheng, Di; Che, Honglei; Zhang, Tao; Xu, Xiaoya; Zhou, Ningxin

2014-10-01

To explore and find a new method to treat hilar cholangiocarcinoma with deep jaundice assisted by Da Vinci robot. A hilar cholangiocarcinoma patient of type Bismuch-Corlette IIIa was found with deep jaundice (total bilirubin: 635 µmol/L). On the first admission, we performed Da Vinci robotic surgery including drainage of left hepatic duct, dissection of right hepatic vessels (right portal vein and right hepatic artery), and placement of right-hepatic vascular control device. Three weeks later on the second admission when the jaundice disappeared we occluded right-hepatic vascular discontinuously for 6 days and then sustained later. On the third admission after 3 weeks of right-hepatic vascular control, the right hemihepatectomy was performed by Da Vinci robot for the second time. The future liver remnant after the right-hepatic vascular control increased from 35% to 47%. The volume of left lobe increased by 368 mL. When the total bilirubin and liver function were all normal, right hemihepatectomy was performed by Da Vinci robot 10 weeks after the first operation. The removal of atrophic right hepatic lobe with tumor in bile duct was found with no pathologic cancer remaining in the margin. The patient was followed up at our outpatient clinic every 3 months and no tumor recurrence occurs by now (1 y). Under the Da Vinci robotic surgical system, a programmed treatment can be achieved: first, the hepatic vessels were controlled gradually together with biliary drainage, which results in liver's partial atrophy and compensatory hypertrophy in the other part. Then a radical hepatectomy could be achieved. Such programmed hepatectomy provides a new treatment for patients of hilar cholangiocarcinoma with deep jaundice who have the possibility of radical heptolobectomy.

Adjuvant radiation trials for high-risk breast cancer patients: adequacy of lymphadenectomy.

PubMed

Silberman, A W; Sarna, G P; Palmer, D

2000-06-01

The recently published, widely publicized adjuvant radiation trials from Denmark and Canada concluded that the addition of postoperative radiotherapy (XRT) to modified radical mastectomy (MRM) and adjuvant chemotherapy reduces locoregional recurrences and prolongs survival in high-risk premenopausal patients with breast cancer. Our thesis is that adequate lymphadenectomies were not performed in either study. Consequently, the conclusion to these studies is not applicable to those patients who have undergone adequate surgery. To better assess adequate lymph node yield from an MRM, a retrospective review was performed on 215 consecutive patients treated surgically for invasive breast cancer. Data from this review were compared with the surgical data from the above-mentioned radiotherapy trials. In a group of 131 patients who had MRM, the average number of nodes removed was 26 (median, 25), and 75.5% of the specimens had 20 or more lymph nodes. In 73 patients who underwent segmental mastectomy with axillary lymph node dissection, both the average and the median number of lymph nodes removed were 24, and 68.9% had 20 or more nodes. These data compare to the Danish radiation trial in which a median of 7 lymph nodes were removed (with 76% of the patients having 9 or fewer lymph nodes in the specimen) and to the Canadian radiation trial in which a median of 11 lymph nodes were removed. In addition, in our breast cancer patients with positive nodes (84 of 204; 41.2%), 45.2.% (38 of 84) had more than three positive nodes compared with 29.8% in the Danish study and 35% in the Canadian study. Our surgical data are sufficiently different from those of the Danish and Canadian studies to indicate that, in those studies, incomplete lymph node dissections were performed and that residual disease was left behind in the axilla in some or all of the patients. The addition of XRT in the setting of residual axillary disease may compensate for an inadequate operation and yield an acceptable oncological result; however, these studies did not provide an adequate comparison with a well-performed MRM without XRT. In the absence of documented benefit, XRT should not be routinely added if a complete lymph node dissection has been performed.

A Tree Based Self-routing Scheme for Mobility Support in Wireless Sensor Networks

NASA Astrophysics Data System (ADS)

Kim, Young-Duk; Yang, Yeon-Mo; Kang, Won-Seok; Kim, Jin-Wook; An, Jinung

Recently, WSNs (Wireless Sensor Networks) with mobile robot is a growing technology that offer efficient communication services for anytime and anywhere applications. However, the tiny sensor node has very limited network resources due to its low battery power, low data rate, node mobility, and channel interference constraint between neighbors. Thus, in this paper, we proposed a tree based self-routing protocol for autonomous mobile robots based on beacon mode and implemented in real test-bed environments. The proposed scheme offers beacon based real-time scheduling for reliable association process between parent and child nodes. In addition, it supports smooth handover procedure by reducing flooding overhead of control packets. Throughout the performance evaluation by using a real test-bed system and simulation, we illustrate that our proposed scheme demonstrates promising performance for wireless sensor networks with mobile robots.

Robotic liver surgery: technical aspects and review of the literature

PubMed Central

Bianco, Francesco Maria; Daskalaki, Despoina; Gonzalez-Ciccarelli, Luis Fernando; Kim, Jihun; Benedetti, Enrico

2016-01-01

Minimally invasive surgery for liver resections has a defined role and represents an accepted alternative to open techniques for selected cases. Robotic technology can overcome some of the disadvantages of the laparoscopic technique, mainly in the most complex cases. Precise dissection and microsuturing is possible, even in narrow operative fields, allowing for a better dissection of the hepatic hilum, fine lymphadenectomy, and biliary reconstruction even with small bile ducts and easier bleeding control. This technique has the potential to allow for a greater number of major resections and difficult segmentectomies to be performed in a minimally invasive fashion. The implementation of near-infrared fluorescence with indocyanine green (ICG) also allows for a more accurate recognition of vascular and biliary anatomy. The perspectives of this kind of virtually implemented imaging are very promising and may be reflected in better outcomes. The overall data present in current literature suggests that robotic liver resections are at least comparable to both open and laparoscopic surgery in terms of perioperative and postoperative outcomes. This article provides technical details of robotic liver resections and a review of the current literature. PMID:27500143

Robotic Versus Video-assisted Lobectomy/Segmentectomy for Lung Cancer: A Meta-analysis.

PubMed

Liang, Hengrui; Liang, Wenhua; Zhao, Lei; Chen, Difei; Zhang, Jianrong; Zhang, Yiyin; Tang, Shiyan; He, Jianxing

2017-06-16

: Objective: To compare the safety/efficacy of the robotic-assisted lobectomy/segmentectomy (RAL/S) with the video-assisted lobectomy/segmentectomy (VAL/S) for radical lung cancer resection. It remains uncertain whether the newly developed RAL/S is comparable with the VAL/S. A comprehensive search of online databases was performed. Perioperative outcomes were synthesized. Cumulative meta-analysis was performed to evaluate the temporal trend of pooled outcomes. Specific subgroups (propensity score matching studies, pure lobectomy studies) were examined. Analysis of 14 studies including a total of 7438 patients was performed. RAL/S was performed on 3239 patients, whereas the other 4199 patients underwent VAL/S. The 30-day mortality [0.7% vs 1.1%; odds ratio (OR) 0.53, P = 0.045] and conversion rate to open surgery (10.3% vs 11.9%; OR 0.57, P < 0.001) were significantly lower in patients who underwent RAL/S than VAL/S. Meanwhile, the postoperative complications (27.5% vs 28.2%; OR 0.95, P = 0.431), operation time [176.63 vs 162.74 min; standardized mean difference (SMD) 0.30, P = 0.086], duration of hospitalization (4.90 vs 5.23 days; SMD -0.08, P = 0.292), days to tube removal (4.10 vs 3.53 days; SMD 0.25, P = 0.120), retrieved lymph node (11.96 vs 10.67; SMD 0.46, P = 0.381), and retrieved lymph node station (4.98 vs 4.32; SMD 0.83, P = 0.261) were similar between the 2 groups. The cumulative meta-analyses suggested that the relative effects between 2 groups have already stabilized. All outcomes of subgroup and overall analyses were similar. This up-to-date meta-analysis confirms that RAL/S is a feasible and safe alternative to VAL/S for radical resection of lung cancer. Future studies should focus on the long-term benefits and cost effectiveness of RAL/S compared with VAL/S.

Tumor laterality in early ovarian cancer: influence on left-right asymmetry of pelvic lymph nodes.

PubMed

Mujezinović, Faris; Takac, Iztok

2010-01-01

AIM AND BACKGROUND.:To determine whether left-right asymmetry was present in cases of early ovarian cancer and whether or not the difference between number of removed lymph nodes on both sides of the pelvis is associated with tumor laterality. We extracted from the medical data base cases of early ovarian cancer with lymphadenectomy who had been treated between 1994 and 2008. The sample was divided in three groups according to the left-right laterality of the tumor in the pelvis (bilateral, left sided, right sided). For each case, we subtracted the number of dissected lymph nodes on the left side from the number of dissected lymph nodes on the right side of the pelvis (N(Right side) - N(Left side)). We used one sample t test to determine whether the mean of differences for each group was different from zero. Results. We extracted 48 cases with early ovarian cancer who had undergone lymphadenectomy. The average number of dissected lymph nodes was 24 (SD, 12). In 3 cases, we confirmed the presence of lymph node metastasis (6.3%). In 2 of the upstaged cases, tumor and involved lymph nodes were on the right side of the pelvis. In the third case, the tumor was on the left side, whereas involved lymph nodes were on both sides of the pelvis. For bilateral tumors, tumors on the left, and those on the right side of the pelvis, the mean difference was -0.5 (95% CI, -9.9 to 8.9; t, -0.137; P = 0.90), 0.32 (95% CI, -3.8 to 4.5; t, 0.16; P = 0.87) and 3.5 (95% CI, 0.03 to 7.01; t, 2.09; P = 0.048), respectively. When the tumor was on the left or on both sides of the pelvis, there was no significant difference in the number of removed lymph nodes. In contrast, when the tumor was on the right side, the number of removed lymph nodes was significantly higher on the right hemipelvis than on the left hemipelvis.

Does elective neck dissection in T1/T2 carcinoma of the oral tongue and floor of the mouth influence recurrence and survival rates?

PubMed

Kelner, Natalie; Vartanian, José Guilherme; Pinto, Clóvis Antônio Lopes; Coutinho-Camillo, Cláudia Malheiros; Kowalski, Luiz Paulo

2014-09-01

The aim of this study was to evaluate the results of elective neck dissection compared with observation (control group) in selected cases of early carcinoma of the oral tongue and floor of the mouth. It was a retrospective analysis of 222 patients who had the tumour resected (161 also had elective neck dissection). Occult lymph node metastases were detected in 33/161 (21%), and neck recurrences were diagnosed in 10 of the 61 patients in the control group (16%). Occult lymph node metastases reduced the 5-year disease-specific survival from 90% to 65% (p=0.001) and it was 96% among the controls. The 5-year disease-specific survival was 85% in the group treated by neck dissection and 96% in the observation group (p=0.09). Rigorous follow-up of selected low risk patients is associated with high rates of salvage, and overall survival was similar to the observed survival in patients treated by elective neck dissection. Observation is a reasonable option in the treatment of selected patients. Copyright © 2014 The British Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.

Health resource utilization and costs during the first 90 days following robot-assisted hysterectomy.

PubMed

Dandolu, Vani; Pathak, Prathamesh

2018-06-01

To compare health resource utilization, costs and readmission rates between robot-assisted and non-robot-assisted hysterectomy during the 90 days following surgery. The study used 2008-2012 Truven Health MarketScan data. All patients admitted as inpatients with a CPT code for hysterectomy between January 2008 and September 2012 were identified and the first hysterectomy-related admission in each patient was included. Patients were categorized based on the route of their hysterectomy and the use of laparoscopy as: total abdominal hysterectomy, vaginal hysterectomy (VH), laparoscopy-assisted supracervical hysterectomy, laparoscopy-assisted vaginal hysterectomy' and total laparoscopic hysterectomy (TLH). Hospitalization costs, including hospital, physician, pharmacy and facility costs, were calculated for the index admissions and for the 90-day follow-up periods. Health resource utilization was determined in terms of inpatient readmissions, outpatient visits, and emergency room visits, RESULTS: There were 302,923 hysterectomies performed over 5 years for benign indications in the inpatient setting (55% abdominal, 17% vaginal, and 28% laparoscopic). Concurrent use of robot assistance steadily increased and was reported in 50% of TLH procedures in 2012. The rates of readmission overall were 4.9% for robot-assisted procedures and 4.3% for procedures without robot assistance (OR 0.89, CI 0.82-0.97). Readmission rates were lowest for VH (3.2%) and highest for TLH (5.6%). Following robot-assisted hysterectomy and VH, 8.3% and 4.6% of patients, respectively, had more than ten outpatient visits in the 90-day follow-up period. The average total cost for 90 days was $16,820 for robot-assisted hysterectomy and $13,031 for procedures without robot assistance. Of the additional costs for robot-assisted surgery, 25% were incurred in the 90-day follow-up period. The study using private insurance data found that robot-assisted hysterectomy was associated with higher health resource utilization and costs than other minimally invasive approaches. Given the high costs associated with robot-assisted hysterectomy, it is important to understand the specific indications for this approach and to identify the patients who may benefit.

Robot-assisted general surgery.

PubMed

Hazey, Jeffrey W; Melvin, W Scott

2004-06-01

With the initiation of laparoscopic techniques in general surgery, we have seen a significant expansion of minimally invasive techniques in the last 16 years. More recently, robotic-assisted laparoscopy has moved into the general surgeon's armamentarium to address some of the shortcomings of laparoscopic surgery. AESOP (Computer Motion, Goleta, CA) addressed the issue of visualization as a robotic camera holder. With the introduction of the ZEUS robotic surgical system (Computer Motion), the ability to remotely operate laparoscopic instruments became a reality. US Food and Drug Administration approval in July 2000 of the da Vinci robotic surgical system (Intuitive Surgical, Sunnyvale, CA) further defined the ability of a robotic-assist device to address limitations in laparoscopy. This includes a significant improvement in instrument dexterity, dampening of natural hand tremors, three-dimensional visualization, ergonomics, and camera stability. As experience with robotic technology increased and its applications to advanced laparoscopic procedures have become more understood, more procedures have been performed with robotic assistance. Numerous studies have shown equivalent or improved patient outcomes when robotic-assist devices are used. Initially, robotic-assisted laparoscopic cholecystectomy was deemed safe, and now robotics has been shown to be safe in foregut procedures, including Nissen fundoplication, Heller myotomy, gastric banding procedures, and Roux-en-Y gastric bypass. These techniques have been extrapolated to solid-organ procedures (splenectomy, adrenalectomy, and pancreatic surgery) as well as robotic-assisted laparoscopic colectomy. In this chapter, we review the evolution of robotic technology and its applications in general surgical procedures.

[Experimental study on the lymph flow of the esophagus by injecting cuttlefish particles into the esophageal wall].

PubMed

Nakano, S

1994-04-01

Cuttlefish particles which have an affinity with lymphatic pathways are useful for investigating the lymph flow from the esophagus, because they can be distinguished from anthracosis in the thoracic lymph nodes by means of melanine breeching method. Four days after injecting the cuttlefish particles into the esophageal walls of 103 mongrel dogs, intrathoracic and abdominal lymph nodes were dissected and examined histologically to know how much of the injected particles have migrated into lymph nodes. In case of spreading of injected particles limited to the muscle layer, the staining rate per number of cases in the right uppermost mediastinal nodes was higher when the particles were injected into the upper and middle esophagus (75%) than into the lower esophagus (0%, p < 0.002). The rate of staining in the lymph nodes along the left gastric artery was higher when the particles were injected into the anal side (100%) than into the oral side of the canter of middle esophagus (14%, p < 0.001). If these situations were duplicated in humans, lymph node dissection for thoracic esophageal cancer should reasonably be considered from the findings on tumor location and depth of invasion by the tumor.

Human-Robot Interaction: Does Robotic Guidance Force Affect Gait-Related Brain Dynamics during Robot-Assisted Treadmill Walking?

PubMed Central

Knaepen, Kristel; Mierau, Andreas; Swinnen, Eva; Fernandez Tellez, Helio; Michielsen, Marc; Kerckhofs, Eric; Lefeber, Dirk; Meeusen, Romain

2015-01-01

In order to determine optimal training parameters for robot-assisted treadmill walking, it is essential to understand how a robotic device interacts with its wearer, and thus, how parameter settings of the device affect locomotor control. The aim of this study was to assess the effect of different levels of guidance force during robot-assisted treadmill walking on cortical activity. Eighteen healthy subjects walked at 2 km.h-1 on a treadmill with and without assistance of the Lokomat robotic gait orthosis. Event-related spectral perturbations and changes in power spectral density were investigated during unassisted treadmill walking as well as during robot-assisted treadmill walking at 30%, 60% and 100% guidance force (with 0% body weight support). Clustering of independent components revealed three clusters of activity in the sensorimotor cortex during treadmill walking and robot-assisted treadmill walking in healthy subjects. These clusters demonstrated gait-related spectral modulations in the mu, beta and low gamma bands over the sensorimotor cortex related to specific phases of the gait cycle. Moreover, mu and beta rhythms were suppressed in the right primary sensory cortex during treadmill walking compared to robot-assisted treadmill walking with 100% guidance force, indicating significantly larger involvement of the sensorimotor area during treadmill walking compared to robot-assisted treadmill walking. Only marginal differences in the spectral power of the mu, beta and low gamma bands could be identified between robot-assisted treadmill walking with different levels of guidance force. From these results it can be concluded that a high level of guidance force (i.e., 100% guidance force) and thus a less active participation during locomotion should be avoided during robot-assisted treadmill walking. This will optimize the involvement of the sensorimotor cortex which is known to be crucial for motor learning. PMID:26485148

Perioperative outcomes of video- and robot-assisted segmentectomies.

PubMed

Rinieri, Philippe; Peillon, Christophe; Salaün, Mathieu; Mahieu, Julien; Bubenheim, Michael; Baste, Jean-Marc

2016-02-01

Video-assisted thoracic surgery appears to be technically difficult for segmentectomy. Conversely, robotic surgery could facilitate the performance of segmentectomy. The aim of this study was to compare the early results of video- and robot-assisted segmentectomies. Data were collected prospectively on videothoracoscopy from 2010 and on robotic procedures from 2013. Fifty-one patients who were candidates for minimally invasive segmentectomy were included in the study. Perioperative outcomes of video-assisted and robotic segmentectomies were compared. The minimally invasive segmentectomies included 32 video- and 16 robot-assisted procedures; 3 segmentectomies (2 video-assisted and 1 robot-assisted) were converted to lobectomies. Four conversions to thoracotomy were necessary for anatomical reason or arterial injury, with no uncontrolled bleeding in the robotic arm. There were 7 benign or infectious lesions, 9 pre-invasive lesions, 25 lung cancers, and 10 metastatic diseases. Patient characteristics, type of segment, conversion to thoracotomy, conversion to lobectomy, operative time, postoperative complications, chest tube duration, postoperative stay, and histology were similar in the video and robot groups. Estimated blood loss was significantly higher in the video group (100 vs. 50 mL, p = 0.028). The morbidity rate of minimally invasive segmentectomy was low. The short-term results of video-assisted and robot-assisted segmentectomies were similar, and more data are required to show any advantages between the two techniques. Long-term oncologic outcomes are necessary to evaluate these new surgical practices. © The Author(s) 2016.

Robot assistant versus human or another robot assistant in patients undergoing laparoscopic cholecystectomy.

PubMed

Gurusamy, Kurinchi Selvan; Samraj, Kumarakrishnan; Fusai, Giuseppe; Davidson, Brian R

2012-09-12

The role of a robotic assistant in laparoscopic cholecystectomy is controversial. While some trials have shown distinct advantages of a robotic assistant over a human assistant others have not, and it is unclear which robotic assistant is best. The aims of this review are to assess the benefits and harms of a robot assistant versus human assistant or versus another robot assistant in laparoscopic cholecystectomy, and to assess whether the robot can substitute the human assistant. We searched the Cochrane Central Register of Controlled Trials (CENTRAL) in The Cochrane Library, MEDLINE, EMBASE, and Science Citation Index Expanded (until February 2012) for identifying the randomised clinical trials. Only randomised clinical trials (irrespective of language, blinding, or publication status) comparing robot assistants versus human assistants in laparoscopic cholecystectomy were considered for the review. Randomised clinical trials comparing different types of robot assistants were also considered for the review. Two authors independently identified the trials for inclusion and independently extracted the data. We calculated the risk ratio (RR) or mean difference (MD) with 95% confidence interval (CI) using the fixed-effect and the random-effects models based on intention-to-treat analysis, when possible, using Review Manager 5. We included six trials with 560 patients. One trial involving 129 patients did not state the number of patients randomised to the two groups. In the remaining five trials 431 patients were randomised, 212 to the robot assistant group and 219 to the human assistant group. All the trials were at high risk of bias. Mortality and morbidity were reported in only one trial with 40 patients. There was no mortality or morbidity in either group. Mortality and morbidity were not reported in the remaining trials. Quality of life or the proportion of patients who were discharged as day-patient laparoscopic cholecystectomy patients were not reported in any trial. There was no significant difference in the proportion of patients who required conversion to open cholecystectomy (2 trials; 4/63 (weighted proportion 6.4%) in the robot assistant group versus 5/70 (7.1%) in the human assistant group; RR 0.90; 95% CI 0.25 to 3.20). There was no significant difference in the operating time between the two groups (4 trials; 324 patients; MD 5.00 minutes; 95% CI -0.55 to 10.54). In one trial, about one sixth of the laparoscopic cholecystectomies in which a robot assistant was used required temporary use of a human assistant. In another trial, there was no requirement for human assistants. One trial did not report this information. It appears that there was little or no requirement for human assistants in the other three trials. There were no randomised trials comparing one type of robot versus another type of robot. Robot assisted laparoscopic cholecystectomy does not seem to offer any significant advantages over human assisted laparoscopic cholecystectomy. However, all trials had a high risk of systematic errors or bias (that is, risk of overestimation of benefit and underestimation of harm). All trials were small, with few or no outcomes. Hence, the risk of random errors (that is, play of chance) is high. Further randomised trials with low risk of bias or random errors are needed.

Robot-assisted Ivor-Lewis esophagectomy with intrathoracic robot-sewn anastomosis.

PubMed

Jin, Runsen; Xiang, Jie; Han, Dingpei; Zhang, Yajie; Li, Hecheng

2017-11-01

This video clip demonstrated a performance of robot-assisted Ivor-Lewis esophagectomy with intrathoracic robot-sewn anastomosis. The patient had an esophageal mass located approximately 33 cm away from incisor, and robot-assisted Ivor-Lewis esophagectomy was applied for him. Importantly, a double-layer esophago-gastric anastomosis was made by robotic hand-sewn suture. Our early experience demonstrated that the robot-sewn intrathoracic anastomosis is feasible and safe with a lower complication rate and the absence of anastomotic leakage.

Socially assistive robotics for post-stroke rehabilitation

PubMed Central

Matarić, Maja J; Eriksson, Jon; Feil-Seifer, David J; Winstein, Carolee J

2007-01-01

Background Although there is a great deal of success in rehabilitative robotics applied to patient recovery post stroke, most of the research to date has dealt with providing physical assistance. However, new rehabilitation studies support the theory that not all therapy need be hands-on. We describe a new area, called socially assistive robotics, that focuses on non-contact patient/user assistance. We demonstrate the approach with an implemented and tested post-stroke recovery robot and discuss its potential for effectiveness. Results We describe a pilot study involving an autonomous assistive mobile robot that aids stroke patient rehabilitation by providing monitoring, encouragement, and reminders. The robot navigates autonomously, monitors the patient's arm activity, and helps the patient remember to follow a rehabilitation program. We also show preliminary results from a follow-up study that focused on the role of robot physical embodiment in a rehabilitation context. Conclusion We outline and discuss future experimental designs and factors toward the development of effective socially assistive post-stroke rehabilitation robots. PMID:17309795

Pelvic lymph node dissection in early ovarian cancer: success of retrieval of lymph nodes by individual lymph node groups in respect to pelvic laterality.

PubMed

Mujezinović, Faris; Takac, Iztok

2010-08-01

To evaluate the differences in number of harvested retroperitoneal pelvic lymph nodes by specific lymph node regions in respect to pelvic laterality. We extracted cases of early ovarian cancer (EOC) with lymphadenectomy from the medical database which were treated at our institution in the period between 1994 and 2008. Recommendations of FIGO and EGSOC (European Guidelines for Staging in Ovarian Cancer) for staging of ovarian malignancies were followed. Stage of the disease was established on the basis of intra-abdominal condition which we found during surgery and histopathologic status of retroperitoneal lymph nodes (LN). For each case and every LN group, we subtracted the number of dissected lymph nodes on the left side from the number of dissected lymph nodes on the right side of the pelvis. The result would represent the difference between number of removed LN on each side of the pelvis for specific LN group. A negative difference means that a greater number of LN was extracted from the left side and a positive difference that the greater number of LN was extracted from the right side of the pelvis. We used Wilcoxon signed-rank test for statistical analysis of differences. 48 cases with EOC underwent lymphadenectomy. In three cases, metastatic retroperitoneal pelvic lymph nodes were found. There were 79.1%, 50.0%, 45.8%, 93.8%, 52.1%, 60.4% and 70.8% of cases with left-right difference in number of removed lymph nodes in external iliac region, common iliac region, presacralic, above obturator nerve, under obturator nerve, lateral from the external ilac vessels and lateral from the common iliac vessels nodal group, respectively. The mean differences between left and right groups were in the range from 2 to 4 lymph nodes. There was no identifiable bias toward either side of the pelvis for any of the analyzed lymph node groups. There is a right and left prevalence of retrieved LN by individual LN regions in the pelvis that could be influenced by asymmetry in right-left pelvic LN distribution. However, we did not find any evidence that the observed imbalance is, on average, directed toward either side of the pelvis. Copyright 2010 Elsevier Ireland Ltd. All rights reserved.

Full robot-assisted gastrectomy with intracorporeal robot-sewn anastomosis produces satisfying outcomes

PubMed Central

Liu, Xin-Xin; Jiang, Zhi-Wei; Chen, Ping; Zhao, Yan; Pan, Hua-Feng; Li, Jie-Shou

2013-01-01

AIM: To evaluate the feasibility and safety of full robot-assisted gastrectomy with intracorporeal robot hand-sewn anastomosis in the treatment of gastric cancer. METHODS: From September 2011 to March 2013, 110 consecutive patients with gastric cancer at the authors’ institution were enrolled for robotic gastrectomies. According to tumor location, total gastrectomy, distal or proximal subtotal gastrectomy with D2 lymphadenectomy was fully performed by the da Vinci Robotic Surgical System. All construction, including Roux-en-Y jejunal limb, esophagojejunal, gastroduodenal and gastrojejunal anastomoses were fully carried out by the intracorporeal robot-sewn method. At the end of surgery, the specimen was removed through a 3-4 cm incision at the umbilicus trocar point. The details of the surgical technique are well illustrated. The benefits in terms of surgical and oncologic outcomes are well documented, as well as the failure rate and postoperative complications. RESULTS: From a total of 110 enrolled patients, radical gastrectomy could not be performed in 2 patients due to late stage disease; 1 patient was converted to laparotomy because of uncontrollable hemorrhage, and 1 obese patient was converted due to difficult exposure; 2 patients underwent extra-corporeal anastomosis by minilaparotomy to ensure adequate tumor margin. Robot-sewn anastomoses were successfully performed for 12 proximal, 38 distal and 54 total gastrectomies. The average surgical time was 272.52 ± 53.91 min and the average amount of bleeding was 80.78 ± 32.37 mL. The average number of harvested lymph nodes was 23.1 ± 5.3. All specimens showed adequate surgical margin. With regard to tumor staging, 26, 32 and 46 patients were staged as I, II and III, respectively. The average hospitalization time after surgery was 6.2 d. One patient experienced a duodenal stump anastomotic leak, which was mild and treated conservatively. One patient was readmitted for intra-abdominal infection and was treated conservatively. Jejunal afferent loop obstruction occurred in 1 patient, who underwent re-operation and recovered quickly. CONCLUSION: This technique is feasible and can produce satisfying postoperative outcomes. It is also convenience and reliable for anastomoses in gastrectomy. Full robotic hand-sewn anastomosis may be a minimally invasive technique for gastrectomy surgery. PMID:24151361

Experimental analysis of robot-assisted needle insertion into porcine liver.

PubMed

Wang, Wendong; Shi, Yikai; Goldenberg, Andrew A; Yuan, Xiaoqing; Zhang, Peng; He, Lijing; Zou, Yingjie

2015-01-01

How to improve placement accuracy of needle insertion into liver tissue is of paramount interest to physicians. A robot-assisted system was developed to experimentally demonstrate its advantages in needle insertion surgeries. Experiments of needle insertion into porcine liver tissue were performed with conic tip needle (diameter 8 mm) and bevel tip needle (diameter 1.5 mm) in this study. Manual operation was designed to compare the performance of the presented robot-assisted system. The real-time force curves show outstanding advantages of robot-assisted operation in improving the controllability and stability of needle insertion process by comparing manual operation. The statistics of maximum force and average force further demonstrates robot-assisted operation causes less oscillation. The difference of liver deformation created by manual operation and robot-assisted operation is very low, 1 mm for average deformation and 2 mm for maximum deformation. To conclude, the presented robot-assisted system can improve placement accuracy of needle by stably control insertion process.

Outcome following sentinel lymph node biopsy-guided decisions in breast cancer patients with conversion from positive to negative axillary lymph nodes after neoadjuvant chemotherapy.

PubMed

Kang, Young-Joon; Han, Wonshik; Park, Soojin; You, Ji Young; Yi, Ha Woo; Park, Sungmin; Nam, Sanggeun; Kim, Joo Heung; Yun, Keong Won; Kim, Hee Jeong; Ahn, Sei Hyun; Park, Seho; Lee, Jeong Eon; Lee, Eun Sook; Noh, Dong-Young; Lee, Jong Won

2017-11-01

Many breast cancer patients with positive axillary lymph nodes achieve complete node remission after neoadjuvant chemotherapy. The usefulness of sentinel lymph node biopsy in this situation is uncertain. This study evaluated the outcomes of sentinel biopsy-guided decisions in patients who had conversion of axillary nodes from clinically positive to negative following neoadjuvant chemotherapy. We reviewed the records of 1247 patients from five hospitals in Korea who had breast cancer with clinically axillary lymph node-positive status and negative conversion after neoadjuvant chemotherapy, between 2005 and 2012. Patients who underwent axillary operations with sentinel biopsy-guided decisions (Group A) were compared with patients who underwent complete axillary lymph node dissection without sentinel lymph node biopsy (Group B). Axillary node recurrence and distant recurrence-free survival were compared. There were 428 cases in Group A and 819 in Group B. Kaplan-Meier analysis showed that recurrence-free survivals were not significantly different between Groups A and B (4-year axillary recurrence-free survival: 97.8 vs. 99.0%; p = 0.148). Multivariate analysis also indicated the two groups had no significant difference in axillary and distant recurrence-free survival. For breast cancer patients who had clinical conversion of axillary lymph nodes from positive to negative following neoadjuvant chemotherapy, sentinel biopsy-guided axillary surgery, and axillary lymph node dissection without sentinel lymph node biopsy had similar rates of recurrence. Thus, sentinel biopsy-guided axillary operation in breast cancer patients who have clinically axillary lymph node positive to negative conversion following neoadjuvant chemotherapy is a useful strategy.

Impact of false-negative sentinel lymph node biopsy on survival in patients with cutaneous melanoma.

PubMed

Caracò, C; Marone, U; Celentano, E; Botti, G; Mozzillo, N

2007-09-01

Sentinel lymph node biopsy is widely accepted as standard care in melanoma despite lack of pertinent randomized trials results. A possible pitfall of this procedure is the inaccurate identification of the sentinel lymph node leading to biopsy and analysis of a nonsentinel node. Such a technical failure may yield a different prognosis. The purpose of this study is to analyze the incidence of false negativity and its impact on clinical outcome and to try to understand its causes. The Melanoma Data Base at National Cancer Institute of Naples was analyzed comparing results between false-negative and tumor-positive sentinel node patients focusing on overall survival and prognostic factors influencing the clinical outcome. One hundred fifty-one cases were diagnosed to be tumor-positive after sentinel lymph node biopsy and were subjected to complete lymph node dissection. Thirty-four (18.4%)patients with tumor-negative sentinel node subsequently developed lymph node metastases in the basin site of the sentinel procedure. With a median follow-up of 42.8 months the 5-year overall survival was 48.4% and 66.3% for false-negative and tumor-positive group respectively with significant statistical differences (P < .03). The sensitivity of sentinel lymph node biopsy was 81.6%, and a regional nodal basin recurrence after negative-sentinel node biopsy means a worse prognosis, compared with patients submitted to complete lymph node dissection after a positive sentinel biopsy. The evidence of higher number of tumor-positive nodes after delayed lymphadenectomy in false-negative group compared with tumor-positive sentinel node cases, confirmed the importance of an early staging of lymph nodal involvement. Further data will better clarify the role of prognostic factors to identify cases with a more aggressive biological behavior of the disease.

Robotic Lunar Landers For Science And Exploration

NASA Technical Reports Server (NTRS)

Cohen, B. A.; Bassler, J. A.; Morse, B. J.; Reed, C. L. B.

2010-01-01

NASA Marshall Space Flight Center and The Johns Hopkins University Applied Physics Laboratory have been conducting mission studies and performing risk reduction activities for NASA s robotic lunar lander flight projects. In 2005, the Robotic Lunar Exploration Program Mission #2 (RLEP-2) was selected as an ESMD precursor robotic lander mission to demonstrate precision landing and determine if there was water ice at the lunar poles; however, this project was canceled. Since 2008, the team has been supporting SMD designing small lunar robotic landers for science missions, primarily to establish anchor nodes of the International Lunar Network (ILN), a network of lunar geophysical nodes. Additional mission studies have been conducted to support other objectives of the lunar science community. This paper describes the current status of the MSFC/APL robotic lunar mission studies and risk reduction efforts including high pressure propulsion system testing, structure and mechanism development and testing, long cycle time battery testing, combined GN&C and avionics testing, and two autonomous lander test articles.

Robotic hair restoration.

PubMed

Rose, Paul T; Nusbaum, Bernard

2014-01-01

The latest innovation to hair restoration surgery has been the introduction of a robotic system for harvesting grafts. This system uses the follicular unit extraction/follicular isolation technique method for harvesting follicular units, which is particularly well suited to the abilities of a robotic technology. The ARTAS system analyzes images of the donor area and then a dual-chamber needle and blunt dissecting punch are used to harvest the follicular units. The robotic technology is now being used in various locations around the world. This article discusses the use of the robotic system, its capabilities, and the advantages and disadvantages of the system. Copyright © 2014 Elsevier Inc. All rights reserved.

Impressions of Humanness for Android Robot may Represent an Endophenotype for Autism Spectrum Disorders.

PubMed

Kumazaki, Hirokazu; Warren, Zachary; Swanson, Amy; Yoshikawa, Yuichiro; Matsumoto, Yoshio; Ishiguro, Hiroshi; Sarkar, Nilanjan; Minabe, Yoshio; Kikuchi, Mitsuru

2018-02-01

Identification of meaningful endophenotypes may be critical to unraveling the etiology and pathophysiology of autism spectrum disorders (ASD). We investigated whether impressions of "humanness" for android robot might represent a candidate characteristic of an ASD endophenotype. We used a female type of android robot with an appearance similar to that of a real person. Significant differences in overall impressions of 'humanness' for android robot were found between adolescents with ASD and typical development (TD) controls, as well as parents of children with ASD and parents of TD controls. Our current work does suggest robotic systems could potentially play an intelligent role in dissecting ASD heterogeneity.

Extraperitoneal Robotic-Assisted Para-Aortic Lymphadenectomy in Gynecologic Cancer Staging: Current Evidence.

PubMed

Bogani, Giorgio; Ditto, Antonino; Martinelli, Fabio; Signorelli, Mauro; Chiappa, Valentina; Sabatucci, Ilaria; Scaffa, Cono; Lorusso, Domenica; Raspagliesi, Francesco

2016-01-01

We reviewed the current evidence on the safety, effectiveness, and applicability of extraperitoneal robotic-assisted para-aortic lymphadenectomy (ExtRA-PAL) as the staging procedure of gynecologic malignancies. PubMed (MEDLINE), Scopus, Web of Science databases, and ClinicalTrials.gov were searched for original studies reporting outcomes of ExtRA-PAL. Quality of the included studies and their level of recommendation were assessed using the Grading of Recommendations, Assessment, Development, and Evaluation and the American College of Obstetricians and Gynecologists guidelines, respectively. Overall, 62 studies were identified; after a process of evidence acquisition 5 original investigations were available for this review that included 98 patients undergoing ExtRA-PAL. The main surgical indication was staging for cervical cancer (n = 71, 72%). The mean (SD) number of para-aortic node yielded was 15.4 (±4.7) nodes. Blood transfusion and intraoperative complication rates were 2% and 6%, respectively. ExtRA-PAL was completed in 88 patients (90%). Six (6%) and 4 (4%) patients had conversion to other minimally invasive procedures and open surgery, respectively. Success rate was 99% among patients undergoing ExtRA-PAL without concomitant procedures. Overall, mean (SD) length of hospital stay was 2.8 (±0.5) days. Twenty-four patients (24%) developed postoperative events. According to the Clavien-Dindo grading system, grades IIIa and IIIb morbidity rates were 12% and 2%, respectively. No grades IV and V morbidity occurred. ExtRA-PAL is associated with a high success rate and a relative low morbidity rate. However, because of the limited data on this issue, further studies are warranted to assess the long-term effectiveness of this procedure. Copyright © 2016 AAGL. Published by Elsevier Inc. All rights reserved.

Use of Pediatric Open, Laparoscopic and Robot-Assisted Laparoscopic Ureteral Reimplantation in the United States: 2000 to 2012.

PubMed

Bowen, Diana K; Faasse, Mark A; Liu, Dennis B; Gong, Edward M; Lindgren, Bruce W; Johnson, Emilie K

2016-07-01

We characterize the use of pediatric open, laparoscopic and robot-assisted laparoscopic ureteral reimplantation in the United States from 2000 to 2012. We used the Kids' Inpatient Database to identify patients who underwent ureteral reimplantation for primary vesicoureteral reflux. Before 2009 laparoscopic ureteral reimplantion and robot-assisted laparoscopic ureteral reimplantation were referred to together as minimally invasive ureteral reimplantation. A detailed analysis of open vs robot-assisted laparoscopic ureteral reimplantation was performed for 2009 and 2012. A total of 14,581 ureteral reimplantations were performed. The number of ureteral reimplantations yearly decreased by 14.3%. However, the proportion of minimally invasive ureteral reimplantations increased from 0.3% to 6.3%. A total of 125 robot-assisted laparoscopic ureteral reimplantations were performed in 2012 (81.2% of minimally invasive ureteral reimplantations), representing 5.1% of all ureteral reimplantations, compared to 3.8% in 2009. In 2009 and 2012 mean ± SD patient age was 5.7 ± 3.6 years for robot-assisted laparoscopic ureteral reimplantation and 4.3 ± 3.3 years for open reimplantation (p <0.0001). Mean ± SD length of hospitalization was 1.6 ± 1.3 days for robot-assisted laparoscopic ureteral reimplantation and 2.4 ± 2.6 for open reimplantation (p <0.0001). Median charges were $22,703 for open and $32,409 for robot-assisted laparoscopic ureteral reimplantation (p <0.0001). These relationships maintained significance on multivariate analyses. On multivariate analysis robot-assisted laparoscopic ureteral reimplantation use was associated with public insurance status (p = 0.04) and geographic region outside of the southern United States (p = 0.02). Only 50 of 456 hospitals used both approaches (open and robotic), and only 6 hospitals reported 5 or more robot-assisted laparoscopic ureteral reimplantations during 2012. Treatment of primary vesicoureteral reflux with ureteral reimplantation is decreasing. Robot-assisted laparoscopic ureteral reimplantation is becoming more prevalent but remains relatively uncommon. Length of stay is shorter for the robotic approach but the costs are higher. Nationally robot-assisted laparoscopic ureteral reimplantation appears to still be in the early phase of adoption and is clustered at a small number of hospitals. Copyright © 2016 American Urological Association Education and Research, Inc. Published by Elsevier Inc. All rights reserved.

Computer-assisted hip and knee arthroplasty. Navigation and active robotic systems: an evidence-based analysis.

PubMed

2004-01-01

The Medical Advisory Secretariat undertook a review of the evidence on the effectiveness and cost-effectiveness of computer assisted hip and knee arthroplasty. The two computer assisted arthroplasty systems that are the topics of this review are (1) navigation and (2) robotic-assisted hip and knee arthroplasty. Computer-assisted arthroplasty consists of navigation and robotic systems. Surgical navigation is a visualization system that provides positional information about surgical tools or implants relative to a target bone on a computer display. Most of the navigation-assisted arthroplasty devices that are the subject of this review are licensed by Health Canada. Robotic systems are active robots that mill bone according to information from a computer-assisted navigation system. The robotic-assisted arthroplasty devices that are the subject of this review are not currently licensed by Health Canada. The Cochrane and International Network of Agencies for Health Technology Assessment databases did not identify any health technology assessments on navigation or robotic-assisted hip or knee arthroplasty. The MEDLINE and EMBASE databases were searched for articles published between January 1, 1996 and November 30, 2003. This search produced 367 studies, of which 9 met the inclusion criteria. NAVIGATION-ASSISTED ARTHROPLASTY: Five studies were identified that examined navigation-assisted arthroplasty.A Level 1 evidence study from Germany found a statistically significant difference in alignment and angular deviation between navigation-assisted and free-hand total knee arthroplasty in favour of navigation-assisted surgery. However, the endpoints in this study were short-term. To date, the long-term effects (need for revision, implant longevity, pain, functional performance) are unknown.(1)A Level 2 evidence short-term study found that navigation-assisted total knee arthroplasty was significantly better than a non-navigated procedure for one of five postoperative measured angles.(2)A Level 2 evidence short-term study found no statistically significant difference in the variation of the abduction angle between navigation-assisted and conventional total hip arthroplasty.(3)Level 3 evidence observational studies of navigation-assisted total knee arthroplasty and unicompartmental knee arthroplasty have been conducted. Two studies reported that "the follow-up of the navigated prostheses is currently too short to know if clinical outcome or survival rates are improved. Longer follow-up is required to determine the respective advantages and disadvantages of both techniques."(4;5) ROBOTIC-ASSISTED ARTHROPLASTY: Four studies were identified that examined robotic-assisted arthroplasty.A Level 1 evidence study revealed that there was no statistically significant difference between functional hip scores at 24 months post implantation between patients who underwent robotic-assisted primary hip arthroplasty and those that were treated with manual implantation.(6)Robotic-assisted arthroplasty had advantages in terms of preoperative planning and the accuracy of the intraoperative procedure.(6)Patients who underwent robotic-assisted hip arthroplasty had a higher dislocation rate and more revisions.(6)Robotic-assisted arthroplasty may prove effective with certain prostheses (e.g., anatomic) because their use may result in less muscle detachment.(6)An observational study (Level 3 evidence) found that the incidence of severe embolic events during hip relocation was lower with robotic arthroplasty than with manual surgery.(7)An observational study (Level 3 evidence) found that there was no significant difference in gait analyses of patients who underwent robotic-assisted total hip arthroplasty using robotic surgery compared to patients who were treated with conventional cementless total hip arthroplasty.(8)An observational study (Level 3 evidence) compared outcomes of total knee arthroplasty between patients undergoing robotic surgery and patients who were historical controls. Brief, qualitative results suggested that there was much broader variation of angles after manual total knee arthroplasty compared to the robotic technique and that there was no difference in knee functional scores or implant position at the 3 and 6 month follow-up.(9).

Computer-Assisted Hip and Knee Arthroplasty. Navigation and Active Robotic Systems

PubMed Central

2004-01-01

Executive Summary Objective The Medical Advisory Secretariat undertook a review of the evidence on the effectiveness and cost-effectiveness of computer assisted hip and knee arthroplasty. The two computer assisted arthroplasty systems that are the topics of this review are (1) navigation and (2) robotic-assisted hip and knee arthroplasty. The Technology Computer-assisted arthroplasty consists of navigation and robotic systems. Surgical navigation is a visualization system that provides positional information about surgical tools or implants relative to a target bone on a computer display. Most of the navigation-assisted arthroplasty devices that are the subject of this review are licensed by Health Canada. Robotic systems are active robots that mill bone according to information from a computer-assisted navigation system. The robotic-assisted arthroplasty devices that are the subject of this review are not currently licensed by Health Canada. Review Strategy The Cochrane and International Network of Agencies for Health Technology Assessment databases did not identify any health technology assessments on navigation or robotic-assisted hip or knee arthroplasty. The MEDLINE and EMBASE databases were searched for articles published between January 1, 1996 and November 30, 2003. This search produced 367 studies, of which 9 met the inclusion criteria. Summary of Findings Navigation-Assisted Arthroplasty Five studies were identified that examined navigation-assisted arthroplasty. A Level 1 evidence study from Germany found a statistically significant difference in alignment and angular deviation between navigation-assisted and free-hand total knee arthroplasty in favour of navigation-assisted surgery. However, the endpoints in this study were short-term. To date, the long-term effects (need for revision, implant longevity, pain, functional performance) are unknown.(1) A Level 2 evidence short-term study found that navigation-assisted total knee arthroplasty was significantly better than a non-navigated procedure for one of five postoperative measured angles.(2) A Level 2 evidence short-term study found no statistically significant difference in the variation of the abduction angle between navigation-assisted and conventional total hip arthroplasty.(3) Level 3 evidence observational studies of navigation-assisted total knee arthroplasty and unicompartmental knee arthroplasty have been conducted. Two studies reported that “the follow-up of the navigated prostheses is currently too short to know if clinical outcome or survival rates are improved. Longer follow-up is required to determine the respective advantages and disadvantages of both techniques.”(4;5) Robotic-Assisted Arthroplasty Four studies were identified that examined robotic-assisted arthroplasty. A Level 1 evidence study revealed that there was no statistically significant difference between functional hip scores at 24 months post implantation between patients who underwent robotic-assisted primary hip arthroplasty and those that were treated with manual implantation.(6) Robotic-assisted arthroplasty had advantages in terms of preoperative planning and the accuracy of the intraoperative procedure.(6) Patients who underwent robotic-assisted hip arthroplasty had a higher dislocation rate and more revisions.(6) Robotic-assisted arthroplasty may prove effective with certain prostheses (e.g., anatomic) because their use may result in less muscle detachment.(6) An observational study (Level 3 evidence) found that the incidence of severe embolic events during hip relocation was lower with robotic arthroplasty than with manual surgery.(7) An observational study (Level 3 evidence) found that there was no significant difference in gait analyses of patients who underwent robotic-assisted total hip arthroplasty using robotic surgery compared to patients who were treated with conventional cementless total hip arthroplasty.(8) An observational study (Level 3 evidence) compared outcomes of total knee arthroplasty between patients undergoing robotic surgery and patients who were historical controls. Brief, qualitative results suggested that there was much broader variation of angles after manual total knee arthroplasty compared to the robotic technique and that there was no difference in knee functional scores or implant position at the 3 and 6 month follow-up.(9) PMID:23074452

A comparative direct cost analysis of pediatric urologic robot-assisted laparoscopic surgery versus open surgery: could robot-assisted surgery be less expensive?

PubMed

Rowe, Courtney K; Pierce, Michael W; Tecci, Katherine C; Houck, Constance S; Mandell, James; Retik, Alan B; Nguyen, Hiep T

2012-07-01

Cost in healthcare is an increasing and justifiable concern that impacts decisions about the introduction of new devices such as the da Vinci(®) surgical robot. Because equipment expenses represent only a portion of overall medical costs, we set out to make more specific cost comparisons between open and robot-assisted laparoscopic surgery. We performed a retrospective, observational, matched cohort study of 146 pediatric patients undergoing either open or robot-assisted laparoscopic urologic surgery from October 2004 to September 2009 at a single institution. Patients were matched based on surgery type, age, and fiscal year. Direct internal costs from the institution were used to compare the two surgery types across several procedures. Robot-assisted surgery direct costs were 11.9% (P=0.03) lower than open surgery. This cost difference was primarily because of the difference in hospital length of stay between patients undergoing open vs robot-assisted surgery (3.8 vs 1.6 days, P<0.001). Maintenance fees and equipment expenses were the primary contributors to robotic surgery costs, while open surgery costs were affected most by room and board expenses. When estimates of the indirect costs of robot purchase and maintenance were included, open surgery had a lower total cost. There were no differences in follow-up times or complication rates. Direct costs for robot-assisted surgery were significantly lower than equivalent open surgery. Factors reducing robot-assisted surgery costs included: A consistent and trained robotic surgery team, an extensive history of performing urologic robotic surgery, selection of patients for robotic surgery who otherwise would have had longer hospital stays after open surgery, and selection of procedures without a laparoscopic alternative. The high indirect costs of robot purchase and maintenance remain major factors, but could be overcome by high surgical volume and reduced prices as competitors enter the market.

Laparoscopic retroperitoneal lymph node dissection for testicular cancer

PubMed Central

Hillelsohn, Joel H.; Duty, Brian D.; Okhunov, Zhamshid; Kavoussi, Louis R.

2012-01-01

Objectives Laparoscopic retroperitoneal lymph node dissection (L-RPLND) was introduced over 20 years ago as a less invasive alternative to open node dissection. In this review we summarise the indications, surgical technique and outcomes of L-RPLND in the treatment of testicular cancer. Methods We searched MEDLINE using the terms ‘laparoscopy’, ‘laparoscopic’, ‘retroperitoneal lymph node dissection’, ‘RPLND’ and ‘testicular neoplasms’. Articles were selected on the basis of their relevance, study design and content, with an emphasis on more recent data. Results We found 14 pertinent studies, which included >1300 patients who received either L-RPLND (515) or open RPLND (788). L-RPLND was associated with longer mean operative times (204 vs. 186 min), but shorter hospital stays (3.3 vs. 6.6 days) and lower complication rates (15.6% vs. 33%). Oncological outcomes were similar between L-RPLND and open RPLND, with local relapse rates of 1.3% and 1.4%, incidence of distal progression of 3.3% and 6.1%, biochemical failure in 0.9% and 1.1% and cure rates of 100% and 99.6%, respectively. Conclusion There are no randomised controlled studies comparing L-RPLND with open RPLND. A review of case and comparative series showed similar perioperative and oncological outcomes. Patients undergoing L-RPLND on average have shorter hospital stays, a quicker return to normal activity and improved cosmesis. PMID:26558006

Human-robot interaction tests on a novel robot for gait assistance.

PubMed

Tagliamonte, Nevio Luigi; Sergi, Fabrizio; Carpino, Giorgio; Accoto, Dino; Guglielmelli, Eugenio

2013-06-01

This paper presents tests on a treadmill-based non-anthropomorphic wearable robot assisting hip and knee flexion/extension movements using compliant actuation. Validation experiments were performed on the actuators and on the robot, with specific focus on the evaluation of intrinsic backdrivability and of assistance capability. Tests on a young healthy subject were conducted. In the case of robot completely unpowered, maximum backdriving torques were found to be in the order of 10 Nm due to the robot design features (reduced swinging masses; low intrinsic mechanical impedance and high-efficiency reduction gears for the actuators). Assistance tests demonstrated that the robot can deliver torques attracting the subject towards a predicted kinematic status.

Energy optimization in mobile sensor networks

NASA Astrophysics Data System (ADS)

Yu, Shengwei

Mobile sensor networks are considered to consist of a network of mobile robots, each of which has computation, communication and sensing capabilities. Energy efficiency is a critical issue in mobile sensor networks, especially when mobility (i.e., locomotion control), routing (i.e., communications) and sensing are unique characteristics of mobile robots for energy optimization. This thesis focuses on the problem of energy optimization of mobile robotic sensor networks, and the research results can be extended to energy optimization of a network of mobile robots that monitors the environment, or a team of mobile robots that transports materials from stations to stations in a manufacturing environment. On the energy optimization of mobile robotic sensor networks, our research focuses on the investigation and development of distributed optimization algorithms to exploit the mobility of robotic sensor nodes for network lifetime maximization. In particular, the thesis studies these five problems: 1. Network-lifetime maximization by controlling positions of networked mobile sensor robots based on local information with distributed optimization algorithms; 2. Lifetime maximization of mobile sensor networks with energy harvesting modules; 3. Lifetime maximization using joint design of mobility and routing; 4. Optimal control for network energy minimization; 5. Network lifetime maximization in mobile visual sensor networks. In addressing the first problem, we consider only the mobility strategies of the robotic relay nodes in a mobile sensor network in order to maximize its network lifetime. By using variable substitutions, the original problem is converted into a convex problem, and a variant of the sub-gradient method for saddle-point computation is developed for solving this problem. An optimal solution is obtained by the method. Computer simulations show that mobility of robotic sensors can significantly prolong the lifetime of the whole robotic sensor network while consuming negligible amount of energy for mobility cost. For the second problem, the problem is extended to accommodate mobile robotic nodes with energy harvesting capability, which makes it a non-convex optimization problem. The non-convexity issue is tackled by using the existing sequential convex approximation method, based on which we propose a novel procedure of modified sequential convex approximation that has fast convergence speed. For the third problem, the proposed procedure is used to solve another challenging non-convex problem, which results in utilizing mobility and routing simultaneously in mobile robotic sensor networks to prolong the network lifetime. The results indicate that joint design of mobility and routing has an edge over other methods in prolonging network lifetime, which is also the justification for the use of mobility in mobile sensor networks for energy efficiency purpose. For the fourth problem, we include the dynamics of the robotic nodes in the problem by modeling the networked robotic system using hybrid systems theory. A novel distributed method for the networked hybrid system is used to solve the optimal moving trajectories for robotic nodes and optimal network links, which are not answered by previous approaches. Finally, the fact that mobility is more effective in prolonging network lifetime for a data-intensive network leads us to apply our methods to study mobile visual sensor networks, which are useful in many applications. We investigate the joint design of mobility, data routing, and encoding power to help improving the video quality while maximizing the network lifetime. This study leads to a better understanding of the role mobility can play in data-intensive surveillance sensor networks.

On the Effectiveness of Robot-Assisted Language Learning

ERIC Educational Resources Information Center

Lee, Sungjin; Noh, Hyungjong; Lee, Jonghoon; Lee, Kyusong; Lee, Gary Geunbae; Sagong, Seongdae; Kim, Munsang

2011-01-01

This study introduces the educational assistant robots that we developed for foreign language learning and explores the effectiveness of robot-assisted language learning (RALL) which is in its early stages. To achieve this purpose, a course was designed in which students have meaningful interactions with intelligent robots in an immersive…

Robot Acquisition of Active Maps Through Teleoperation and Vector Space Analysis

NASA Technical Reports Server (NTRS)

Peters, Richard Alan, II

2003-01-01

The work performed under this contract was in the area of intelligent robotics. The problem being studied was the acquisition of intelligent behaviors by a robot. The method was to acquire action maps that describe tasks as sequences of reflexive behaviors. Action maps (a.k.a. topological maps) are graphs whose nodes represent sensorimotor states and whose edges represent the motor actions that cause the robot to proceed from one state to the next. The maps were acquired by the robot after being teleoperated or otherwise guided by a person through a task several times. During a guided task, the robot records all its sensorimotor signals. The signals from several task trials are partitioned into episodes of static behavior. The corresponding episodes from each trial are averaged to produce a task description as a sequence of characteristic episodes. The sensorimotor states that indicate episode boundaries become the nodes, and the static behaviors, the edges. It was demonstrated that if compound maps are constructed from a set of tasks then the robot can perform new tasks in which it was never explicitly trained.

The learning curve of robot-assisted radical cystectomy: results from the International Robotic Cystectomy Consortium.

PubMed

Hayn, Matthew H; Hussain, Abid; Mansour, Ahmed M; Andrews, Paul E; Carpentier, Paul; Castle, Erik; Dasgupta, Prokar; Rimington, Peter; Thomas, Raju; Khan, Shamim; Kibel, Adam; Kim, Hyung; Manoharan, Murugesan; Menon, Mani; Mottrie, Alex; Ornstein, David; Peabody, James; Pruthi, Raj; Palou Redorta, Joan; Richstone, Lee; Schanne, Francis; Stricker, Hans; Wiklund, Peter; Chandrasekhar, Rameela; Wilding, Greg E; Guru, Khurshid A

2010-08-01

Robot-assisted radical cystectomy (RARC) has evolved as a minimally invasive alternative to open radical cystectomy for patients with invasive bladder cancer. We sought to define the learning curve for RARC by evaluating results from a multicenter, contemporary, consecutive series of patients who underwent this procedure. Utilizing the International Robotic Cystectomy Consortium database, a prospectively maintained and institutional review board-approved database, we identified 496 patients who underwent RARC by 21 surgeons at 14 institutions from 2003 to 2009. Cut-off points for operative time, lymph node yield (LNY), estimated blood loss (EBL), and margin positivity were identified. Using specifically designed statistical mixed models, we were able to inversely predict the number of patients required for an institution to reach the predetermined cut-off points. Mean operative time was 386 min, mean EBL was 408 ml, and mean LNY was 18. Overall, 34 of 482 patients (7%) had a positive surgical margin (PSM). Using statistical models, it was estimated that 21 patients were required for operative time to reach 6.5h and 8, 20, and 30 patients were required to reach an LNY of 12, 16, and 20, respectively. For all patients, PSM rates of <5% were achieved after 30 patients. For patients with pathologic stage higher than T2, PSM rates of <15% were achieved after 24 patients. RARC is a challenging procedure but is a technique that is reproducible throughout multiple centers. This report helps to define the learning curve for RARC and demonstrates an acceptable level of proficiency by the 30th case for proxy measures of RARC quality. Copyright (c) 2010 European Association of Urology. Published by Elsevier B.V. All rights reserved.

Assistance dogs provide a useful behavioral model to enrich communicative skills of assistance robots.

PubMed

Gácsi, Márta; Szakadát, Sára; Miklósi, Adám

2013-01-01

These studies are part of a project aiming to reveal relevant aspects of human-dog interactions, which could serve as a model to design successful human-robot interactions. Presently there are no successfully commercialized assistance robots, however, assistance dogs work efficiently as partners for persons with disabilities. In Study 1, we analyzed the cooperation of 32 assistance dog-owner dyads performing a carrying task. We revealed typical behavior sequences and also differences depending on the dyads' experiences and on whether the owner was a wheelchair user. In Study 2, we investigated dogs' responses to unforeseen difficulties during a retrieving task in two contexts. Dogs displayed specific communicative and displacement behaviors, and a strong commitment to execute the insoluble task. Questionnaire data from Study 3 confirmed that these behaviors could successfully attenuate owners' disappointment. Although owners anticipated the technical competence of future assistance robots to be moderate/high, they could not imagine robots as emotional companions, which negatively affected their acceptance ratings of future robotic assistants. We propose that assistance dogs' cooperative behaviors and problem solving strategies should inspire the development of the relevant functions and social behaviors of assistance robots with limited manual and verbal skills.

Sentinel Node Biopsy in Melanoma: A Short Update

PubMed Central

Ferrara, Gerardo; Partenzi, Antonietta; Filosa, Alessandra

2018-01-01

Several controversies are still ongoing about sentinel node biopsy in melanoma. It is basically a staging procedure for melanoma > 0.75 mm in thickness or for thinner melanoma in the presence of ulceration, high mitotic rate, and/or lymphovascular invasion. Complete lymph node dissection after a positive sentinel node can also allow a better locoregional disease control but seems not to prevent the development of distant metastases. The use of sentinel node biopsy in atypical Spitz tumors should be discouraged because of their peculiar biological properties. PMID:29719827

Combined operative technique with anterior surgical approach and video-assisted thoracoscopic surgical lobectomy for anterior superior sulcus tumours.

PubMed

Yokoyama, Yuhei; Chen, Fengshi; Aoyama, Akihiro; Sato, Toshihiko; Date, Hiroshi

2014-11-01

Video-assisted thoracoscopic surgery (VATS) has been widely used, but surgical resections of superior sulcus tumours remain challenging because of their anatomical location. For such cases, less-invasive procedures, such as the anterior transcervical-thoracic and transmanubrial approaches, have been widely performed because of their excellent visualization of the subclavian vessels. Recently, a combined operative technique with an anterior surgical approach and VATS for anterior superior sulcus tumours has been introduced. Herein, we report three cases of anterior superior sulcus tumours successfully resected by surgical approaches combined with a VATS-based lobectomy. In all cases, operability was confirmed by VATS, and upper lobectomies with hilar and mediastinal lymph node dissections were performed. Subsequently, dissections of the anterior inlet of the tumours were performed using the transmanubrial approach in two patients and the anterior trans-cervical-thoracic approach in one patient. Both approaches provided excellent access to the anterior inlet of the tumour and exposure of the subclavian vessels, resulting in radical resection of the tumour with concomitant resection of the surrounding anatomical structures, including the chest wall and vessels. In conclusion, VATS lobectomy combined with the anterior surgical approach might be an excellent procedure for the resection of anterior superior sulcus tumours. © The Author 2014. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.

Association between robot-assisted surgery and resection quality in patients with colorectal cancer.

PubMed

Fransgaard, Tina; Pinar, Ismail; Thygesen, Lau Caspar; Gögenur, Ismail

2018-06-01

Resection quality after robot-assisted surgery for colorectal cancer have not previously been investigated in a nationwide study. The aim of the study was to examine the resection quality in robot-assisted versus laparoscopic surgery for colorectal cancer. Furthermore, 30-day mortality, postoperative complications, and conversion to open surgery were investigated. Patients undergoing either laparoscopic or robot-assisted surgery for colorectal cancer between 1 January 2010 and 31 December 2015 were included. The primary outcome was whether R0 resection was achieved. Secondary outcomes were 30-day mortality, postoperative complications, and conversions to laparotomy. A total of 8615 and 3934 patients had a diagnosis of colon cancer and rectal cancer respectively. Of the patients with colon cancer, 511 patients underwent robot-assisted surgery and of the patients with rectal cancer, 706 patients underwent robot-assisted surgery. In the multivariate analysis, patients with colon cancer had an odds ratio (OR) = 0.63 (95%CI 0.45-0.88) for receiving R0 resection in the robot-assisted group compared to laparoscopy. For patients with rectal cancer, the OR was 1.20 (95%CI 0.89-1.61). No difference in 30-day mortality or postoperative complications were observed. The OR of conversion to laparotomy was lower in the robot-assisted group compared to the laparoscopic group in both patients with colon - and rectal cancer. The study showed significant lower odds of receiving R0 resection in patients with colon cancer undergoing robot-assisted surgery. In patients with rectal cancer the robot-assisted surgery non-significantly increased the odds of receiving R0 resection. Copyright © 2018 Elsevier Ltd. All rights reserved.

Lymphatic Leak Occurring After Surgical Lymph Node Dissection: A Preliminary Study Assessing the Feasibility and Outcome of Lymphatic Embolization

DOE Office of Scientific and Technical Information (OSTI.GOV)

Baek, Yoolim; Won, Je Hwan; Kong, Tae-Wook

PurposeTo analyze imaging findings of lymphatic leakage associated with surgical lymph node dissection on lymphangiography and assess the outcome of lymphatic embolization.Materials and MethodsThis retrospective study comprised 21 consecutive patients who were referred for lymphatic intervention between March 2014 and April 2015 due to postsurgical lymphatic leaks. Lymphangiography was performed through inguinal lymph nodes to identify the leak. When a leak was found, lymphatic embolization was performed by fine-needle injection of N-butyl cyanoacrylate into the site of leakage or into an inflow lymphatic vessel or into a pelvic lymph node located below the leakage. Electronic medical records and imaging studiesmore » were reviewed to assess the outcome.ResultLymphangiography revealed single or multiple leaks in all but one patient. Lymphatic embolization was performed in 20 patients with leaks. Including the patient who did not undergo embolization, 17 patients (81.0 %) showed initial response to treatment. Three patients underwent repeated embolization with successful results. The overall success rate was 95.2 %. The mean duration of hospitalization after lymphatic intervention was 5.9 days. During a mean follow-up period of 11 months, two patients developed localized swelling in the groin following lipiodol injection. There were no complications related to lymphatic embolization. Three patients were found to have developed small, asymptomatic lymphoceles on CT or MRI that did not require further treatment.ConclusionLymphangiography is useful for detecting lymphatic leakage occurring after lymph node dissection. Furthermore, lymphatic embolization is feasible, effective, and safe for managing leaks demonstrated on lymphangiography.« less

Randomized controlled trial of robot-assisted gait training with dorsiflexion assistance on chronic stroke patients wearing ankle-foot-orthosis.

PubMed

Yeung, Ling-Fung; Ockenfeld, Corinna; Pang, Man-Kit; Wai, Hon-Wah; Soo, Oi-Yan; Li, Sheung-Wai; Tong, Kai-Yu

2018-06-19

Robot-assisted ankle-foot-orthosis (AFO) can provide immediate powered ankle assistance in post-stroke gait training. Our research team has developed a novel lightweight portable robot-assisted AFO which is capable of detecting walking intentions using sensor feedback of wearer's gait pattern. This study aims to investigate the therapeutic effects of robot-assisted gait training with ankle dorsiflexion assistance. This was a double-blinded randomized controlled trial. Nineteen chronic stroke patients with motor impairment at ankle participated in 20-session robot-assisted gait training for about five weeks, with 30-min over-ground walking and stair ambulation practices. Robot-assisted AFO either provided active powered ankle assistance during swing phase in Robotic Group (n = 9), or torque impedance at ankle joint as passive AFO in Sham Group (n = 10). Functional assessments were performed before and after the 20-session gait training with 3-month Follow-up. Primary outcome measure was gait independency assessed by Functional Ambulatory Category (FAC). Secondary outcome measures were clinical scores including Fugl-Meyer Assessment (FMA), Modified Ashworth Scale (MAS), Berg Balance Scale (BBS), Timed 10-Meter Walk Test (10MWT), Six-minute Walk Test (SMWT), supplemented by gait analysis. All outcome measures were performed in unassisted gait after patients had taken off the robot-assisted AFO. Repeated-measures analysis of covariance was conducted to test the group differences referenced to clinical scores before training. After 20-session robot-assisted gait training with ankle dorsiflexion assistance, the active ankle assistance in Robotic Group induced changes in gait pattern with improved gait independency (all patients FAC ≥ 5 post-training and 3-month follow-up), motor recovery, walking speed, and greater confidence in affected side loading response (vertical ground reaction force + 1.49 N/kg, peak braking force + 0.24 N/kg) with heel strike instead of flat foot touch-down at initial contact (foot tilting + 1.91°). Sham Group reported reduction in affected leg range of motion (ankle dorsiflexion - 2.36° and knee flexion - 8.48°) during swing. Robot-assisted gait training with ankle dorsiflexion assistance could improve gait independency and help stroke patients developing confidence in weight acceptance, but future development of robot-assisted AFO should consider more lightweight and custom-fit design. ClinicalTrials.gov NCT02471248 . Registered 15 June 2015 retrospectively registered.

Successful resection of metachronous para-aortic, Virchow lymph node and liver metastatic recurrence of rectal cancer.

PubMed

Takeshita, Nobuyoshi; Fukunaga, Toru; Kimura, Masayuki; Sugamoto, Yuji; Tasaki, Kentaro; Hoshino, Isamu; Ota, Takumi; Maruyama, Tetsuro; Tamachi, Tomohide; Hosokawa, Takashi; Asai, Yo; Matsubara, Hisahiro

2015-11-28

A 66-year-old female presented with the main complaint of defecation trouble and abdominal distention. With diagnosis of rectal cancer, cSS, cN0, cH0, cP0, cM0 cStage II, Hartmann's operation with D3 lymph node dissection was performed and a para-aortic lymph node and a disseminated node near the primary tumor were resected. Histological examination showed moderately differentiated adenocarcinoma, pSS, pN3, pH0, pP1, pM1 (para-aortic lymph node, dissemination) fStage IV. After the operation, the patient received chemotherapy with FOLFIRI regimen. After 12 cycles of FOLFIRI regimen, computed tomography (CT) detected an 11 mm of liver metastasis in the postero-inferior segment of right hepatic lobe. With diagnosis of liver metastatic recurrence, we performed partial hepatectomy. Histological examination revealed moderately differentiated adenocarcinoma as a metastatic rectal cancer with cut end microscopically positive. After the second operation, the patient received chemotherapy with TS1 alone for 2 years. Ten months after the break, CT detected a 20 mm of para-aortic lymph node metastasis and a 10 mm of lymph node metastasis at the hepato-duodenal ligament. With diagnosis of lymph node metastatic recurrences, we performed lymph node dissection. Histological examination revealed moderately differentiated adenocarcinoma as metastatic rectal cancer in para-aortic and hepato-duodenal ligament areas. After the third operation, we started chemotherapy with modified FOLFOX6 regimen. After 2 cycles of modified FOLFOX6 regimen, due to the onset of neutropenia and liver dysfunction, we switched to capecitabine alone and continued it for 6 mo and then stopped. Eleven months after the break, CT detected two swelling 12 mm of lymph nodes at the left supraclavicular region. With diagnosis of Virchow lymph node metastatic recurrence, we started chemotherapy with capecitabine plus bevacizumab regimen. Due to the onset of neutropenia and hand foot syndrome (Grade 3), we managed to continue capecitabine administration with extension of interval period and dose reduction. After 2 years and 2 mo from starting capecitabine plus bevacizumab regimen, Virchow lymph nodes had slowly grown up to 17 mm. Because no recurrence had been detected besides Virchow lymph nodes for this follow up period, considering the side effects and quality of life, surgical resection was selected. We performed left supraclavicular lymph node dissection. Histological examination revealed moderately differentiated adenocarcinoma as a metastatic rectal cancer. After the fourth operation, the patient selected follow up without chemotherapy. Now we follow up her without recurrence and keep her quality of life high.

[RESEARCH PROGRESS OF PERIPHERAL NERVE SURGERY ASSISTED BY Da Vinci ROBOTIC SYSTEM].

PubMed

Shen, Jie; Song, Diyu; Wang, Xiaoyu; Wang, Changjiang; Zhang, Shuming

2016-02-01

To summarize the research progress of peripheral nerve surgery assisted by Da Vinci robotic system. The recent domestic and international articles about peripheral nerve surgery assisted by Da Vinci robotic system were reviewed and summarized. Compared with conventional microsurgery, peripheral nerve surgery assisted by Da Vinci robotic system has distinctive advantages, such as elimination of physiological tremors and three-dimensional high-resolution vision. It is possible to perform robot assisted limb nerve surgery using either the traditional brachial plexus approach or the mini-invasive approach. The development of Da Vinci robotic system has revealed new perspectives in peripheral nerve surgery. But it has still been at the initial stage, more basic and clinical researches are still needed.

Effect of Regional Hospital Competition and Hospital Financial Status on the Use of Robotic-Assisted Surgery.

PubMed

Wright, Jason D; Tergas, Ana I; Hou, June Y; Burke, William M; Chen, Ling; Hu, Jim C; Neugut, Alfred I; Ananth, Cande V; Hershman, Dawn L

2016-07-01

Despite the lack of efficacy data, robotic-assisted surgery has diffused rapidly into practice. Marketing to physicians, hospitals, and patients has been widespread, but how this marketing has contributed to the diffusion of the technology remains unknown. To examine the effect of regional hospital competition and hospital financial status on the use of robotic-assisted surgery for 5 commonly performed procedures. A cohort study of 221 637 patients who underwent radical prostatectomy, total nephrectomy, partial nephrectomy, hysterectomy, or oophorectomy at 1370 hospitals in the United States from January 1, 2010, to December 31, 2011, was conducted. The association between hospital competition, hospital financial status, and performance of robotic-assisted surgery was examined. The association between hospital competition was measured with the Herfindahl-Hirschman Index (HHI), hospital financial status was estimated as operating margin, and performance of robotic-assisted surgery was examined using multivariate mixed-effects regression models. We identified 221 637 patients who underwent one of the procedures of interest. The cohort included 30 345 patients who underwent radical prostatectomy; 20 802, total nephrectomy; 8060, partial nephrectomy; 134 985, hysterectomy; and 27 445, oophorectomy. Robotic-assisted operations were performed for 20 500 (67.6%) radical prostatectomies, 1405 (6.8%) total nephrectomies, 2759 (34.2%) partial nephrectomies, 14 047 (10.4%) hysterectomies, and 1782 (6.5%) oophorectomies. Use of robotic-assisted surgery increased for each procedure from January 2010 through December 2011. For all 5 operations, increased market competition (as measured by the HHI) was associated with increased use of robotic-assisted surgery. For prostatectomy, the risk ratios (95% CIs) for undergoing a robotic-assisted procedure were 2.20 (1.50-3.24) at hospitals in moderately competitive markets and 2.64 (1.84-3.78) for highly competitive markets compared with noncompetitive markets. For hysterectomy, patients at hospitals in moderately (3.75 [2.26-6.25]) and highly (5.30; [3.27-8.57]) competitive markets were more likely to undergo a robotic-assisted surgery. Increased hospital profitability was associated with use of robotic-assisted surgery only for partial nephrectomy in facilities with medium-high (1.67 [1.13-2.48]) and high (1.50 [0.98-2.29]) operating margins. With analysis limited to patients treated at a hospital that had performed robotic-assisted surgery, there was no longer an association between competition and use of robotic-assisted surgery. Patients undergoing surgery in a hospital in a competitive regional market were more likely to undergo a robotic-assisted procedure. These data imply that regional competition may influence a hospital's decision to acquire a surgical robot.

Robotic Assistance by Impedance Compensation for Hand Movements While Manual Welding.

PubMed

Erden, Mustafa Suphi; Billard, Aude

2016-11-01

In this paper, we present a robotic assistance scheme which allows for impedance compensation with stiffness, damping, and mass parameters for hand manipulation tasks and we apply it to manual welding. The impedance compensation does not assume a preprogrammed hand trajectory. Rather, the intention of the human for the hand movement is estimated in real time using a smooth Kalman filter. The movement is restricted by compensatory virtual impedance in the directions perpendicular to the estimated direction of movement. With airbrush painting experiments, we test three sets of values for the impedance parameters as inspired from impedance measurements with manual welding. We apply the best of the tested sets for assistance in manual welding and perform welding experiments with professional and novice welders. We contrast three conditions: 1) welding with the robot's assistance; 2) with the robot when the robot is passive; and 3) welding without the robot. We demonstrate the effectiveness of the assistance through quantitative measures of both task performance and perceived user's satisfaction. The performance of both the novice and professional welders improves significantly with robotic assistance compared to welding with a passive robot. The assessment of user satisfaction shows that all novice and most professional welders appreciate the robotic assistance as it suppresses the tremors in the directions perpendicular to the movement for welding.

Effect of radiotherapy after mastectomy and axillary surgery on 10-year recurrence and 20-year breast cancer mortality: meta-analysis of individual patient data for 8135 women in 22 randomised trials.

PubMed

McGale, P; Taylor, C; Correa, C; Cutter, D; Duane, F; Ewertz, M; Gray, R; Mannu, G; Peto, R; Whelan, T; Wang, Y; Wang, Z; Darby, S

2014-06-21

Postmastectomy radiotherapy was shown in previous meta-analyses to reduce the risks of both recurrence and breast cancer mortality in all women with node-positive disease considered together. However, the benefit in women with only one to three positive lymph nodes is uncertain. We aimed to assess the effect of radiotherapy in these women after mastectomy and axillary dissection. We did a meta-analysis of individual data for 8135 women randomly assigned to treatment groups during 1964-86 in 22 trials of radiotherapy to the chest wall and regional lymph nodes after mastectomy and axillary surgery versus the same surgery but no radiotherapy. Follow-up lasted 10 years for recurrence and to Jan 1, 2009, for mortality. Analyses were stratified by trial, individual follow-up year, age at entry, and pathological nodal status. 3786 women had axillary dissection to at least level II and had zero, one to three, or four or more positive nodes. All were in trials in which radiotherapy included the chest wall, supraclavicular or axillary fossa (or both), and internal mammary chain. For 700 women with axillary dissection and no positive nodes, radiotherapy had no significant effect on locoregional recurrence (two-sided significance level [2p]>0·1), overall recurrence (rate ratio [RR], irradiated vs not, 1·06, 95% CI 0·76-1·48, 2p>0·1), or breast cancer mortality (RR 1·18, 95% CI 0·89-1·55, 2p>0·1). For 1314 women with axillary dissection and one to three positive nodes, radiotherapy reduced locoregional recurrence (2p<0·00001), overall recurrence (RR 0·68, 95% CI 0·57-0·82, 2p=0·00006), and breast cancer mortality (RR 0·80, 95% CI 0·67-0·95, 2p=0·01). 1133 of these 1314 women were in trials in which systemic therapy (cyclophosphamide, methotrexate, and fluorouracil, or tamoxifen) was given in both trial groups and, for them, radiotherapy again reduced locoregional recurrence (2p<0·00001), overall recurrence (RR 0·67, 95% CI 0·55-0·82, 2p=0·00009), and breast cancer mortality (RR 0·78, 95% CI 0·64-0·94, 2p=0·01). For 1772 women with axillary dissection and four or more positive nodes, radiotherapy reduced locoregional recurrence (2p<0·00001), overall recurrence (RR 0·79, 95% CI 0·69-0·90, 2p=0·0003), and breast cancer mortality (RR 0·87, 95% CI 0·77-0·99, 2p=0·04). After mastectomy and axillary dissection, radiotherapy reduced both recurrence and breast cancer mortality in the women with one to three positive lymph nodes in these trials even when systemic therapy was given. For today's women, who in many countries are at lower risk of recurrence, absolute gains might be smaller but proportional gains might be larger because of more effective radiotherapy. Cancer Research UK, British Heart Foundation, UK Medical Research Council. Copyright © 2014 EBCTCG. Open Access article distributed under the terms of CC BY. Published by Elsevier Ltd. All rights reserved.

Predicting Functional Recovery in Chronic Stroke Rehabilitation Using Event-Related Desynchronization-Synchronization during Robot-Assisted Movement

PubMed Central

Gramigna, Cristina; Franceschetti, Silvana

2016-01-01

Although rehabilitation robotics seems to be a promising therapy in the rehabilitation of the upper limb in stroke patients, consensus is still lacking on its additive effects. Therefore, there is a need for determining the possible success of robotic interventions on selected patients, which in turn determine the necessity for new investigating instruments supporting the treatment decision-making process and customization. The objective of the work presented in this preliminary study was to verify that fully robot assistance would not affect the physiological oscillatory cortical activity related to a functional movement in healthy subjects. Further, the clinical results following the robotic treatment of a chronic stroke patient, who positively reacted to the robotic intervention, were analyzed and discussed. First results show that there is no difference in EEG activation pattern between assisted and no-assisted movement in healthy subjects. Even more importantly, the patient's pretreatment EEG activation pattern in no-assisted movement was completely altered, while it recovered to a quasi-physiological one in robot-assisted movement. The functional improvement following treatment was large. Using pretreatment EEG recording during robot-assisted movement might be a valid approach to assess the potential ability of the patient for recovering. PMID:27057546

Human likeness: cognitive and affective factors affecting adoption of robot-assisted learning systems

NASA Astrophysics Data System (ADS)

Yoo, Hosun; Kwon, Ohbyung; Lee, Namyeon

2016-07-01

With advances in robot technology, interest in robotic e-learning systems has increased. In some laboratories, experiments are being conducted with humanoid robots as artificial tutors because of their likeness to humans, the rich possibilities of using this type of media, and the multimodal interaction capabilities of these robots. The robot-assisted learning system, a special type of e-learning system, aims to increase the learner's concentration, pleasure, and learning performance dramatically. However, very few empirical studies have examined the effect on learning performance of incorporating humanoid robot technology into e-learning systems or people's willingness to accept or adopt robot-assisted learning systems. In particular, human likeness, the essential characteristic of humanoid robots as compared with conventional e-learning systems, has not been discussed in a theoretical context. Hence, the purpose of this study is to propose a theoretical model to explain the process of adoption of robot-assisted learning systems. In the proposed model, human likeness is conceptualized as a combination of media richness, multimodal interaction capabilities, and para-social relationships; these factors are considered as possible determinants of the degree to which human cognition and affection are related to the adoption of robot-assisted learning systems.

Robotic Camera Assistance and Its Benefit in 1033 Traditional Laparoscopic Procedures: Prospective Clinical Trial Using a Joystick-guided Camera Holder.

PubMed

Holländer, Sebastian W; Klingen, Hans Joachim; Fritz, Marliese; Djalali, Peter; Birk, Dieter

2014-11-01

Despite advances in instruments and techniques in laparoscopic surgery, one thing remains uncomfortable: the camera assistance. The aim of this study was to investigate the benefit of a joystick-guided camera holder (SoloAssist®, Aktormed, Barbing, Germany) for laparoscopic surgery and to compare the robotic assistance to human assistance. 1033 consecutive laparoscopic procedures were performed assisted by the SoloAssist®. Failures and aborts were documented and nine surgeons were interviewed by questionnaire regarding their experiences. In 71 of 1033 procedures, robotic assistance was aborted and the procedure was continued manually, mostly because of frequent changes of position, narrow spaces, and adverse angular degrees. One case of short circuit was reported. Emergency stop was necessary in three cases due to uncontrolled movement into the abdominal cavity. Eight of nine surgeons prefer robotic to human assistance, mostly because of a steady image and self-control. The SoloAssist® robot is a reliable system for laparoscopic procedures. Emergency shutdown was necessary in only three cases. Some minor weak spots could have been identified. Most surgeons prefer robotic assistance to human assistance. We feel that the SoloAssist® makes standard laparoscopic surgery more comfortable and further development is desirable, but it cannot fully replace a human assistant.

Robotic-assisted repair of iatrogenic ureteral ligation following robotic-assisted hysterectomy.

PubMed

Kalisvaart, Jonathan F; Finley, David S; Ornstein, David K

2008-01-01

Ureteral injuries, while rare, do occur during gynecologic procedures. The expansion of laparoscopic and robotic pelvic surgical procedures increases the risk of ureteral injury from these procedures and suggests a role for minimally invasive approaches to the delayed repair of ureteral injuries. We present, to our knowledge, the first case of delayed robotic-assisted ureteral deligation and ureterolysis following iatrogenic ureteral injury occurring during a robotic abdominal hysterectomy. We present a case report and review of the literature. A 57-year-old female underwent a seemingly uncomplicated robotic-assisted laparoscopic total abdominal hysterectomy and bilateral oophorectomy for symptomatic fibroids. On postoperative day 8, she presented with persistent right flank pain. Imaging studies revealed high-grade ureteral obstruction consistent with suture ligation of the right ureter. She underwent successful robotic-assisted ureteral deligation and ureterolysis. Her postoperative course was unremarkable, and she was discharged home on postoperative day 1 from the deligation. Robotic-assisted management of complications from urologic or gynecologic surgery is technically feasible. This can potentially preserve the advantages to the patient that are being seen from the initial less-invasive surgery.

Numeric pathologic lymph node classification shows prognostic superiority to topographic pN classification in esophageal squamous cell carcinoma.

PubMed

Sugawara, Kotaro; Yamashita, Hiroharu; Uemura, Yukari; Mitsui, Takashi; Yagi, Koichi; Nishida, Masato; Aikou, Susumu; Mori, Kazuhiko; Nomura, Sachiyo; Seto, Yasuyuki

2017-10-01

The current eighth tumor node metastasis lymph node category pathologic lymph node staging system for esophageal squamous cell carcinoma is based solely on the number of metastatic nodes and does not consider anatomic distribution. We aimed to assess the prognostic capability of the eighth tumor node metastasis pathologic lymph node staging system (numeric-based) compared with the 11th Japan Esophageal Society (topography-based) pathologic lymph node staging system in patients with esophageal squamous cell carcinoma. We retrospectively reviewed the clinical records of 289 patients with esophageal squamous cell carcinoma who underwent esophagectomy with extended lymph node dissection during the period from January 2006 through June 2016. We compared discrimination abilities for overall survival, recurrence-free survival, and cancer-specific survival between these 2 staging systems using C-statistics. The median number of dissected and metastatic nodes was 61 (25% to 75% quartile range, 45 to 79) and 1 (25% to 75% quartile range, 0 to 3), respectively. The eighth tumor node metastasis pathologic lymph node staging system had a greater ability to accurately determine overall survival (C-statistics: tumor node metastasis classification, 0.69, 95% confidence interval, 0.62-0.76; Japan Esophageal Society classification; 0.65, 95% confidence interval, 0.58-0.71; P = .014) and cancer-specific survival (C-statistics: tumor node metastasis classification, 0.78, 95% confidence interval, 0.70-0.87; Japan Esophageal Society classification; 0.72, 95% confidence interval, 0.64-0.80; P = .018). Rates of total recurrence rose as the eighth tumor node metastasis pathologic lymph node stage increased, while stratification of patients according to the topography-based node classification system was not feasible. Numeric nodal staging is an essential tool for stratifying the oncologic outcomes of patients with esophageal squamous cell carcinoma even in the cohort in which adequate numbers of lymph nodes were harvested. Copyright © 2017 Elsevier Inc. All rights reserved.

The efficacy of physiotherapy upon shoulder function following axillary dissection in breast cancer, a randomized controlled study

PubMed Central

Beurskens, Carien HG; van Uden, Caro JT; Strobbe, Luc JA; Oostendorp, Rob AB; Wobbes, Theo

2007-01-01

Background Many patients suffer from severe shoulder complaints after breast cancer surgery and axillary lymph node dissection. Physiotherapy has been clinically observed to improve treatment of these patients. However, it is not a standard treatment regime. The purpose of this study is to investigate the efficacy of physiotherapy treatment of shoulder function, pain and quality of life in patients who have undergone breast cancer surgery and axillary lymph node dissection. Methods Thirty patients following breast cancer surgery and axillary lymph node dissection were included in a randomised controlled study. Assessments were made at baseline and after three and six months. The treatment group received standardised physiotherapy treatment of advice and exercises for the arm and shoulder for three months; the control group received a leaflet containing advice and exercises. If necessary soft tissue massage to the surgical scar was applied. Primary outcome variables were amount of pain in the shoulder/arm recorded on the Visual Analogue Scale, and shoulder mobility (flexion, abduction) measured using a digital inclinometer under standardized conditions. Secondary outcome measures were shoulder disabilities during daily activities, edema, grip strength of both hands and quality of life. The researcher was blinded to treatment allocation. Results All thirty patients completed the trial. After three and six months the treatment group showed a significant improvement in shoulder mobility and had significantly less pain than the control group. Quality of life improved significantly, however, handgrip strength and arm volume did not alter significantly. Conclusion Physiotherapy reduces pain and improves shoulder function and quality of life following axillary dissection after breast cancer. Trial registration ISRCTN31186536 PMID:17760981

A Dynamic Non Energy Storing Guidance Constraint with Motion Redirection for Robot Assisted Surgery

DTIC Science & Technology

2016-12-01

Abstract— Haptically enabled hands-on or tele-operated surgical robotic systems provide a unique opportunity to integrate pre- and intra... robot -assisted surgical systems aim at improving and extending human capabilities, by exploiting the advantages of robotic systems while keeping the...move during the operation. Robot -assisted beating heart surgery is an example of procedures that can benefit from dynamic constraints. Their

Robotic-Assisted Knee Arthroplasty: An Overview.

PubMed

van der List, Jelle P; Chawla, Harshvardhan; Pearle, Andrew D

2016-01-01

Unicompartmental knee arthroplasty and total knee arthroplasty are reliable treatment options for osteoarthritis. In order to improve survivorship rates, variables that are intraoperatively controlled by the orthopedic surgeon are being evaluated. These variables include lower leg alignment, soft tissue balance, joint line maintenance, and tibial and femoral component alignment, size, and fixation methods. Since tighter control of these factors is associated with improved outcomes of knee arthroplasty, several computer-assisted surgery systems have been developed. These systems differ in the number and type of variables they control. Robotic-assisted systems control these aforementioned variables and, in addition, aim to improve the surgical precision of the procedure. Robotic-assisted systems are active, semi-active, or passive, depending on how independently the systems perform maneuvers. Reviewing the robotic-assisted knee arthroplasty systems, it becomes clear that these systems can accurately and reliably control the aforementioned variables. Moreover, these systems are more accurate and reliable in controlling these variables when compared to the current gold standard of conventional manual surgery. At present, few studies have assessed the survivorship and functional outcomes of robotic-assisted surgery, and no sufficiently powered studies were identified that compared survivorship or functional outcomes between robotic-assisted and conventional knee arthroplasty. Although preliminary outcomes of robotic-assisted surgery look promising, more studies are necessary to assess if the increased accuracy and reliability in controlling the surgical variables leads to better outcomes of robotic-assisted knee arthroplasty.

Identification of spinal tissues loaded by manual therapy: a robot-based serial dissection technique applied in porcine motion segments.

PubMed

Kawchuk, Gregory N; Carrasco, Alejandro; Beecher, Grayson; Goertzen, Darrell; Prasad, Narasimha

2010-10-15

Serial dissection of porcine motion segments during robotic control of vertebral kinematics. To identify which spinal tissues are loaded in response to manual therapy (manipulation and mobilization) and to what magnitude. Various theoretical constructs attempt to explain how manual therapies load specific spinal tissues. By using a parallel robot to control vertebral kinematics during serial dissection, it is possible to quantify the loads experienced by discrete spinal tissues undergoing common therapeutic procedures such as manual therapy. In 9 porcine cadavers, manual therapy was provided to L3 and the kinematic response of L3-L4 recorded. The exact kinematic trajectory experienced by L3-L4 in response to manual therapy was then replayed to the isolated segment by a parallel robot equipped with a 6-axis load cell. Discrete spinal tissues were then removed and the kinematic pathway replayed. The change in forces and moments following tissue removal were considered to be those applied to that specific tissue by manual therapy. In this study, both manual therapies affected spinal tissues. The intervertebral disc experienced the greatest forces and moments arising from both manipulation and mobilization. This study is the first to identify which tissues are loaded in response to manual therapy. The observation that manual therapy loads some tissues to a much greater magnitude than others offers a possible explanation for its modest treatment effect; only conditions involving these tissues may be influenced by manual therapy. Future studies are planned to determine if manual therapy can be altered to target (or avoid) specific spinal tissues.

Anatomic Variability of the Upper Mediastinal Lymph Node Level VII.

PubMed

Hartl, Dana M; Breuskin, Ingrid; Mirghani, Haïtham; Berdelou, Amandine; Déandréis, Désirée; Pottier, Edwige; Borget, Isabelle; Schlumberger, Martin; Leboulleux, Sophie

2016-08-01

Lymph node level VII, between the sternal notch and the innominate artery, is a frequent site of lymph node metastases in thyroid cancer. The objective of this study was to determine the cranial-caudal dimensions of level VII in patients undergoing central neck dissection for thyroid cancer and its accessibility through a neck incision only. Consecutive patients undergoing central neck dissection for thyroid cancer, with no previous neck dissection, mediastinal or thoracic surgery. The innominate artery was identified and the distance between the sternal notch and the upper border of the artery was measured to the nearest .5 mm. The sizes of level VII were compared with respect to age, sex, height, body mass index, type of neck dissection (therapeutic or prophylactic), and the incidence of previous thyroidectomy. One-hundred-one consecutive patients (65 women, 36 men, mean age 44 years (range 15-87) underwent prophylactic (n = 55) or therapeutic (n = 46) bilateral central compartment neck dissection. Level VII was accessible via the horizontal neck incision in all cases. Sizes of level VII ranged from 6 cm above the sternal notch to 35 mm below the sternal notch, with a mean distance of 3.5 mm below the sternal notch. The innominate artery was at the level of the sternal notch in 29 patients, and cranial to the sternal notch in 20 cases. No statistical relationship with age, sex, therapeutic/prophylactic neck dissection, previous surgery, body mass index or height was found. The maximal distance below the sternal notch was 35 mm. Level VII did not exist in 49 % of patients, and was less than 25 mm caudal to the sternal notch in 95 % of cases. Distinguishing level VII from level VI in thyroid cancer surgery may not be pertinent, due to the ease of access via a classic horizontal neck incision and the small sizes of level VII in the majority of patients.

Doing Dissections Differently: A Structured, Peer-Assisted Learning Approach to Maximizing Learning in Dissections

ERIC Educational Resources Information Center

Hall, Emma R.; Davis, Rachel C.; Weller, Renate; Powney, Sonya; Williams, Sarah B.

2013-01-01

Areas of difficulty faced by our veterinary medicine students, with respect to their learning in dissection classes, were identified. These challenges were both general adult-learning related and specific to the discipline of anatomy. Our aim was to design, implement, and evaluate a modified reciprocal peer-assisted/team-based learning…

Assessment of personal care and medical robots from older adults' perspective.

PubMed

Goher, K M; Mansouri, N; Fadlallah, S O

2017-01-01

Demographic reports indicate that population of older adults is growing significantly over the world and in particular in developed nations. Consequently, there are a noticeable number of demands for certain services such as health-care systems and assistive medical robots and devices. In today's world, different types of robots play substantial roles specifically in medical sector to facilitate human life, especially older adults. Assistive medical robots and devices are created in various designs to fulfill specific needs of older adults. Though medical robots are utilized widely by senior citizens, it is dramatic to find out into what extent assistive robots satisfy their needs and expectations. This paper reviews various assessments of assistive medical robots from older adults' perspectives with the purpose of identifying senior citizen's needs, expectations, and preferences. On the other hand, these kinds of assessments inform robot designers, developers, and programmers to come up with robots fulfilling elderly's needs while improving their life quality.

Does assist-as-needed upper limb robotic therapy promote participation in repetitive activity-based motor training in sub-acute stroke patients with severe paresis?

PubMed

Grosmaire, Anne-Gaëlle; Duret, Christophe

2017-01-01

Repetitive, active movement-based training promotes brain plasticity and motor recovery after stroke. Robotic therapy provides highly repetitive therapy that reduces motor impairment. However, the effect of assist-as-needed algorithms on patient participation and movement quality is not known. To analyze patient participation and motor performance during highly repetitive assist-as-needed upper limb robotic therapy in a retrospective study. Sixteen patients with sub-acute stroke carried out a 16-session upper limb robotic training program combined with usual care. The Fugl-Meyer Assessment (FMA) score was evaluated pre and post training. Robotic assistance parameters and Performance measures were compared within and across sessions. Robotic assistance did not change within-session and decreased between sessions during the training program. Motor performance did not decrease within-session and improved between sessions. Velocity-related assistance parameters improved more quickly than accuracy-related parameters. An assist-as-needed-based upper limb robotic training provided intense and repetitive rehabilitation and promoted patient participation and motor performance, facilitating motor recovery.

Robot-assisted partial nephrectomy: Superiority over laparoscopic partial nephrectomy.

PubMed

Shiroki, Ryoichi; Fukami, Naohiko; Fukaya, Kosuke; Kusaka, Mamoru; Natsume, Takahiro; Ichihara, Takashi; Toyama, Hiroshi

2016-02-01

Nephron-sparing surgery has been proven to positively impact the postoperative quality of life for the treatment of small renal tumors, possibly leading to functional improvements. Laparoscopic partial nephrectomy is still one of the most demanding procedures in urological surgery. Laparoscopic partial nephrectomy sometimes results in extended warm ischemic time and severe complications, such as open conversion, postoperative hemorrhage and urine leakage. Robot-assisted partial nephrectomy exploits the advantages offered by the da Vinci Surgical System to laparoscopic partial nephrectomy, equipped with 3-D vision and a better degree in the freedom of surgical instruments. The introduction of the da Vinci Surgical System made nephron-sparing surgery, specifically robot-assisted partial nephrectomy, safe with promising results, leading to the shortening of warm ischemic time and a reduction in perioperative complications. Even for complex and challenging tumors, robotic assistance is expected to provide the benefit of minimally-invasive surgery with safe and satisfactory renal function. Warm ischemic time is the modifiable factor during robot-assisted partial nephrectomy to affect postoperative kidney function. We analyzed the predictive factors for extended warm ischemic time from our robot-assisted partial nephrectomy series. The surface area of the tumor attached to the kidney parenchyma was shown to significantly affect the extended warm ischemic time during robot-assisted partial nephrectomy. In cases with tumor-attached surface area more than 15 cm(2) , we should consider switching robot-assisted partial nephrectomy to open partial nephrectomy under cold ischemia if it is imperative. In Japan, a nationwide prospective study has been carried out to show the superiority of robot-assisted partial nephrectomy to laparoscopic partial nephrectomy in improving warm ischemic time and complications. By facilitating robotic technology, robot-assisted partial nephrectomy will be more frequently carried out as a safe, effective and minimally-invasive nephron-sparing surgery procedure. © 2015 The Japanese Urological Association.

“Five on a dice” port placement for robot-assisted thoracoscopic right upper lobectomy using robotic stapler

PubMed Central

Chan, Edward Y.

2017-01-01

Early versions of the da Vinci robot system (S and Si) have been used to perform pulmonary lung resection with severe limitations. The lack of a vascular robot stapler required the presence of a trained bedside assistant whose role was to place, manipulate and fire the stapler around major vascular structures. Thus, the techniques developed for the Si robot required a skilled bedside assistant to perform stapling of the hilar structure and manipulation of the lung. With the advent of the da Vinci Xi system with a vascular robot stapler, we postulated that we could develop a new port placement and technique to provide total control for the surgeon during the pulmonary lung resection. We found that the “five on a dice” port placement and technique allows for minimal assistance during the lobectomy with full control by the surgeon. This technique uses the full capability of the Xi robot to make the robot-assisted lobectomy a safe and ergonomic operation. PMID:29312746

"Five on a dice" port placement for robot-assisted thoracoscopic right upper lobectomy using robotic stapler.

PubMed

Kim, Min P; Chan, Edward Y

2017-12-01

Early versions of the da Vinci robot system (S and Si) have been used to perform pulmonary lung resection with severe limitations. The lack of a vascular robot stapler required the presence of a trained bedside assistant whose role was to place, manipulate and fire the stapler around major vascular structures. Thus, the techniques developed for the Si robot required a skilled bedside assistant to perform stapling of the hilar structure and manipulation of the lung. With the advent of the da Vinci Xi system with a vascular robot stapler, we postulated that we could develop a new port placement and technique to provide total control for the surgeon during the pulmonary lung resection. We found that the "five on a dice" port placement and technique allows for minimal assistance during the lobectomy with full control by the surgeon. This technique uses the full capability of the Xi robot to make the robot-assisted lobectomy a safe and ergonomic operation.

Retroperitoneal access for robotic renal surgery.

PubMed

Anderson, Barrett G; Wright, Alec J; Potretzke, Aaron M; Figenshau, R Sherburne

2018-01-01

Retroperitoneal access for robotic renal surgery is an effective alternative to the commonly used transperitoneal approach. We describe our contemporary experience and technique for attaining retroperitoneal access. We outline our institutional approach to retroperitoneal access for the instruction of urologists at the beginning of the learning curve. The patient is placed in the lateral decubitus position. The first incision is made just inferior to the tip of the twelfth rib as described by Hsu, et al. After the lumbodorsal fascia is traversed, the retroperitoneal space is dilated with a round 10 millimeter AutoSutureTM (Covidien, Mansfield, MA) balloon access device. The following trocars are used: A 130 millimeter KiiR balloon trocar (Applied Medical, Rancho Santa Margarita, CA), three robotic, and one assistant. Key landmarks for the access and dissection are detailed. 177 patients underwent a retroperitoneal robotic procedure from 2007 to 2015. Procedures performed include 158 partial nephrectomies, 16 pyeloplasties, and three radical nephrectomies. The robotic fourth arm was utilized in all cases. When compared with the transperitoneal approach, the retroperitoneal approach was associated with shorter operative times and decreased length of stay (1). Selection bias and surgeon preference accounted for the higher proportion of patients who underwent partial nephrectomy off-camp via the retroperitoneal approach. Retroperitoneal robotic surgery may confer several advantages. In patients with previous abdominal surgery or intra-abdominal conditions, the retroperitoneum can be safely accessed while avoiding intraperitoneal injuries. The retroperitoneum also provides a confined space that may minimize the sequelae of potential complications including urine leak. Moreover, at our institution, retroperitoneal robotic surgery is associated with shorter operative times and a decreased length of stay when compared with the transperitoneal approach (2). In selected patients, the retroperitoneal approach is a viable alternative to the transperitoneal approach for a variety of renal procedures. Copyright® by the International Brazilian Journal of Urology.

Robot-assisted versus other types of radical prostatectomy: Population-based safety and cost comparison in Japan, 2012–2013

PubMed Central

Sugihara, Toru; Yasunaga, Hideo; Horiguchi, Hiromasa; Matsui, Hiroki; Fujimura, Tetsuya; Nishimatsu, Hiroaki; Fukuhara, Hiroshi; Kume, Haruki; Changhong, Yu; Kattan, Michael W; Fushimi, Kiyohide; Homma, Yukio

2014-01-01

In 2012, Japanese national insurance started covering robot-assisted surgery. We carried out a population-based comparison between robot-assisted and three other types of radical prostatectomy to evaluate the safety of robot-assisted prostatectomy during its initial year. We abstracted data for 7202 open, 2483 laparoscopic, 1181 minimal incision endoscopic, and 2126 robot-assisted radical prostatectomies for oncological stage T3 or less from the Diagnosis Procedure Combination database (April 2012–March 2013). Complication rate, transfusion rate, anesthesia time, postoperative length of stay, and cost were evaluated by pairwise one-to-one propensity-score matching and multivariable analyses with covariants of age, comorbidity, oncological stage, hospital volume, and hospital academic status. The proportion of robot-assisted radical prostatectomies dramatically increased from 8.6% to 24.1% during the first year. Compared with open, laparoscopic, and minimal incision endoscopic surgery, robot-assisted surgery was generally associated with a significantly lower complication rate (odds ratios, 0.25, 0.20, 0.33, respectively), autologous transfusion rate (0.04, 0.31, 0.10), homologous transfusion rate (0.16, 0.48, 0.14), lower cost excluding operation (differences, −5.1%, −1.8% [not significant], −10.8%) and shorter postoperative length of stay (–9.1%, +0.9% [not significant], –18.5%, respectively). However, robot-assisted surgery also resulted in a + 42.6% increase in anesthesia time and +52.4% increase in total cost compared with open surgery (all P < 0.05). Introduction of robotic surgery led to a dynamic change in prostate cancer surgery. Even in its initial year, robot-assisted radical prostatectomy was carried out with several favorable safety aspects compared to the conventional surgeries despite its having the longest anesthesia time and the highest cost. PMID:25183452

Investigating the Effects of Robot-Assisted Therapy among Children with Autism Spectrum Disorder using Bio-markers

NASA Astrophysics Data System (ADS)

Bharatharaj, Jaishankar; Huang, Loulin; Al-Jumaily, Ahmed; Elara, Mohan Rajesh; Krägeloh, Chris

2017-09-01

Therapeutic pet robots designed to help humans with various medical conditions could play a vital role in physiological, psychological and social-interaction interventions for children with autism spectrum disorder (ASD). In this paper, we report our findings from a robot-assisted therapeutic study conducted over seven weeks to investigate the changes in stress levels of children with ASD. For this study, we used the parrot-inspired therapeutic robot, KiliRo, we developed and investigated urinary and salivary samples of participating children to report changes in stress levels before and after interacting with the robot. This is a pioneering human-robot interaction study to investigate the effects of robot-assisted therapy using salivary samples. The results show that the bio-inspired robot-assisted therapy can significantly help reduce the stress levels of children with ASD.

Influence of arm crank ergometry on development of lymphedema in breast cancer patients after axillary dissection: A randomized controlled trail.

PubMed

Schmidt, Thorsten; Berner, Jette; Jonat, Walter; Weisser, Burkhard; Röcken, Christioph; van Mackelenbergh, Marion; Mundhenke, Christoph

2017-01-19

To investigate the safety and efficacy of arm crank ergometry in breast cancer patients after axillary lymph node dissection, with regard to changes in bioelectrical impedance analysis, arm circumference, muscular strength, quality of life and fatigue. Randomized controlled clinical intervention trial. Forty-nine patients with breast cancer after axillary lymph node dissection. Arm crank ergometer training twice-weekly was compared with usual care over 12 weeks. The arm crank ergometer group improved significantly in terms of lean body mass and skeletal muscle mass, and showed a significant decrease in body fat. In the arm crank ergometer group, as well as the usual care group, a significant increase in armpit circumference was detected during the training period. The magnitude of the gain was higher in the usual care group. For all other measured regions of the arm a significant decrease in circumference was seen in both groups. Muscular strength of the upper extremity increased significantly in both groups, with a greater improvement in the arm crank ergometer group. In both groups a non-significant trend towards improvement in quality of life was observed. The arm crank ergometer group showed significant improvements in physical functioning, general fatigue and physical fatigue. These results confirm the feasibility of arm crank ergometer training after axillary lymph node dissection and highlight improvements in strength, quality of life and reduced arm symptoms with this training.

Detection of sentinel lymph nodes in patients with early stage cervical cancer.

PubMed

Seong, Seok Ju; Park, Hyun; Yang, Kwang Moon; Kim, Tae Jin; Lim, Kyung Taek; Shim, Jae Uk; Park, Chong Taik; Lee, Ki Heon

2007-02-01

The purpose of this study was to determine the feasibility of identifying the sentinel lymph nodes (SNs) as well as to evaluate factors that might influence the SN detection rate in patients with cervical cancer of the uterus. Eighty nine patients underwent intracervical injection of 1% isosulfan blue dye at the time of planned radical hysterectomy and lymphadenectomy between January 2003 and December 2003. With the visual detection of lymph nodes that stained blue, SNs were identified and removed separately. Then all patients underwent complete pelvic lymph node dissection and/or para-aortic lymph node dissection. SNs were identified in 51 of 89 (57.3%) patients. The most common site for SN detection was the external iliac area. Metastatic nodes were detected in 21 of 89 (23.5%) patients. One false negative SN was obtained. Successful SN detection was more likely in patients younger than 50 yr (p=0.02) and with a history of preoperative conization (p=0.05). However, stage, histological type, surgical procedure and neoadjuvant chemotherapy showed no significant difference for SN detection rate. Therefore, the identification of SNs with isosulfan blue dye is feasible and safe. The SN detection rate was high in patients younger than 50 yr or with a history of preoperative conization.

N0/N1, PNL, or LNR? The effect of lymph node number on accurate survival prediction in pancreatic ductal adenocarcinoma.

PubMed

Valsangkar, Nakul P; Bush, Devon M; Michaelson, James S; Ferrone, Cristina R; Wargo, Jennifer A; Lillemoe, Keith D; Fernández-del Castillo, Carlos; Warshaw, Andrew L; Thayer, Sarah P

2013-02-01

We evaluated the prognostic accuracy of LN variables (N0/N1), numbers of positive lymph nodes (PLN), and lymph node ratio (LNR) in the context of the total number of examined lymph nodes (ELN). Patients from SEER and a single institution (MGH) were reviewed and survival analyses performed in subgroups based on numbers of ELN to calculate excess risk of death (hazard ratio, HR). In SEER and MGH, higher numbers of ELN improved the overall survival for N0 patients. The prognostic significance (N0/N1) and PLN were too variable as the importance of a single PLN depended on the total number of LN dissected. LNR consistently correlated with survival once a certain number of lymph nodes were dissected (≥13 in SEER and ≥17 in the MGH dataset). Better survival for N0 patients with increasing ELN likely represents improved staging. PLN have some predictive value but the ELN strongly influence their impact on survival, suggesting the need for a ratio-based classification. LNR strongly correlates with outcome provided that a certain number of lymph nodes is evaluated, suggesting that the prognostic accuracy of any LN variable depends on the total number of ELN.

Sentinel Lymph Node Biopsy in Nonmelanoma Skin Cancer Patients

PubMed Central

Matthey-Giè, Marie-Laure; Boubaker, Ariane; Letovanec, Igor; Demartines, Nicolas; Matter, Maurice

2013-01-01

The management of lymph nodes in nonmelanoma skin cancer patients is currently still debated. Merkel cell carcinoma (MCC), squamous cell carcinoma (SCC), pigmented epithelioid melanocytoma (PEM), and other rare skin neoplasms have a well-known risk to spread to regional lymph nodes. The use of sentinel lymph node biopsy (SLNB) could be a promising procedure to assess this risk in clinically N0 patients. Metastatic SNs have been observed in 4.5–28% SCC (according to risk factors), in 9–42% MCC, and in 14–57% PEM. We observed overall 30.8% positive SNs in 13 consecutive patients operated for high-risk nonmelanoma skin cancer between 2002 and 2011 in our institution. These high rates support recommendation to implement SLNB for nonmelanoma skin cancer especially for SCC patients. Completion lymph node dissection following positive SNs is also a matter of discussion especially in PEM. It must be remembered that a definitive survival benefit of SLNB in melanoma patients has not been proven yet. However, because of its low morbidity when compared to empiric elective lymph node dissection or radiation therapy of lymphatic basins, SLNB has allowed sparing a lot of morbidity and could therefore be used in nonmelanoma skin cancer patients, even though a significant impact on survival has not been demonstrated. PMID:23476781

Robots to assist daily activities: views of older adults with Alzheimer's disease and their caregivers.

PubMed

Wang, Rosalie H; Sudhama, Aishwarya; Begum, Momotaz; Huq, Rajibul; Mihailidis, Alex

2017-01-01

Robots have the potential to both enable older adults with dementia to perform daily activities with greater independence, and provide support to caregivers. This study explored perspectives of older adults with Alzheimer's disease (AD) and their caregivers on robots that provide stepwise prompting to complete activities in the home. Ten dyads participated: Older adults with mild-to-moderate AD and difficulty completing activity steps, and their family caregivers. Older adults were prompted by a tele-operated robot to wash their hands in the bathroom and make a cup of tea in the kitchen. Caregivers observed interactions. Semi-structured interviews were conducted individually. Transcribed interviews were thematically analyzed. Three themes summarized responses to robot interactions: contemplating a future with assistive robots, considering opportunities with assistive robots, and reflecting on implications for social relationships. Older adults expressed opportunities for robots to help in daily activities, were open to the idea of robotic assistance, but did not want a robot. Caregivers identified numerous opportunities and were more open to robots. Several wanted a robot, if available. Positive consequences of robots in caregiving scenarios could include decreased frustration, stress, and relationship strain, and increased social interaction via the robot. A negative consequence could be decreased interaction with caregivers. Few studies have investigated in-depth perspectives of older adults with dementia and their caregivers following direct interaction with an assistive prompting robot. To fulfill the potential of robots, continued dialogue between users and developers, and consideration of robot design and caregiving relationship factors are necessary.

Intelligence for Human-Assistant Planetary Surface Robots

NASA Technical Reports Server (NTRS)

Hirsh, Robert; Graham, Jeffrey; Tyree, Kimberly; Sierhuis, Maarten; Clancey, William J.

2006-01-01

The central premise in developing effective human-assistant planetary surface robots is that robotic intelligence is needed. The exact type, method, forms and/or quantity of intelligence is an open issue being explored on the ERA project, as well as others. In addition to field testing, theoretical research into this area can help provide answers on how to design future planetary robots. Many fundamental intelligence issues are discussed by Murphy [2], including (a) learning, (b) planning, (c) reasoning, (d) problem solving, (e) knowledge representation, and (f) computer vision (stereo tracking, gestures). The new "social interaction/emotional" form of intelligence that some consider critical to Human Robot Interaction (HRI) can also be addressed by human assistant planetary surface robots, as human operators feel more comfortable working with a robot when the robot is verbally (or even physically) interacting with them. Arkin [3] and Murphy are both proponents of the hybrid deliberative-reasoning/reactive-execution architecture as the best general architecture for fully realizing robot potential, and the robots discussed herein implement a design continuously progressing toward this hybrid philosophy. The remainder of this chapter will describe the challenges associated with robotic assistance to astronauts, our general research approach, the intelligence incorporated into our robots, and the results and lessons learned from over six years of testing human-assistant mobile robots in field settings relevant to planetary exploration. The chapter concludes with some key considerations for future work in this area.

Infracentimetric cervical lymph node metastasis in head and neck squamous cell carcinoma: Incidence and prognostic value.

PubMed

Pauzie, A; Gavid, M; Dumollard, J-M; Timoshenko, A; Peoc'h, M; Prades, J-M

2016-11-01

Supracentimetric cervical lymph node metastasis is classically a poor prognostic factor for locoregional recurrence and survival in head and neck cancer. Causality, however, is more controversial for infracentimetric cervical lymph node metastases. The objective of this study was to evaluate the incidence and prognostic value of infracentimetric lymph node metastasis. Two hundred and forty-three neck dissections from 150 head and neck cancer patients were analyzed. A single pathologist exhaustively inventoried the number and size of all adenopathies in the surgical specimen. Cervical lymph node metastases were infracentimetric in 38% of cases, with 72% extracapsular spread (versus 91% for supracentimetric adenopathies; P<0.01). Infracentimetric metastases were more often associated with other cervical lymph node metastases (mean 5.3 versus 3.9; P=0.14). Fifty three percent of specimens showed only supracentimetric metastases (versus 13% infracentimetric metastases; P<0.01). Disease-specific and failure-free survival were lower in case of infracentimetric metastasis, associated with supracentimetric metastasis or not, than in case of macrometastasis only. Infracentimetric cervical lymph node metastasis is a factor of poor prognosis, and may represent a different, more aggressive lymphatic process. We suggest complete neck dissection by the surgeon and meticulous analysis by the pathologist, the results of which guide complementary therapy. Close surveillance of recurrence is also recommended. Copyright © 2016 Elsevier Masson SAS. All rights reserved.

ROAD: domestic assistant and rehabilitation robot.

PubMed

Carrera, Isela; Moreno, Héctor A; Saltarén, Roque; Pérez, Carlos; Puglisi, Lisandro; Garcia, Cecilia

2011-10-01

This study introduces the concept design and analysis of a robotic system for the assistance and rehabilitation of disabled people. Based on the statistical data of the most common types of disabilities in Spain and other industrialized countries, the different tasks that the device must be able to perform have been determined. In this study, different robots for rehabilitation and assistance previously introduced have been reviewed. This survey is focused on those robots that assist with gait, balance and standing up. The structure of the ROAD robot presents various advantages over these robots, we discuss some of them. The performance of the proposed architecture is analyzed when it performs the sit to stand activity.

General surgery residents' perception of robot-assisted procedures during surgical training.

PubMed

Farivar, Behzad S; Flannagan, Molly; Leitman, I Michael

2015-01-01

With the continued expansion of robotically assisted procedures, general surgery residents continue to receive more exposure to this new technology as part of their training. There are currently no guidelines or standardized training requirements for robot-assisted procedures during general surgical residency. The aim of this study was to assess the effect of this new technology on general surgery training from the residents' perspective. An anonymous, national, web-based survey was conducted on residents enrolled in general surgery training in 2013. The survey was sent to 240 Accreditation Council for Graduate Medical Education-approved general surgery training programs. Overall, 64% of the responding residents were men and had an average age of 29 years. Half of the responses were from postgraduate year 1 (PGY1) and PGY2 residents, and the remainder was from the PGY3 level and above. Overall, 50% of the responses were from university training programs, 32% from university-affiliated programs, and 18% from community-based programs. More than 96% of residents noted the availability of the surgical robot system at their training institution. Overall, 63% of residents indicated that they had participated in robotic surgical cases. Most responded that they had assisted in 10 or fewer robotic cases with the most frequent activities being assisting with robotic trocar placement and docking and undocking the robot. Only 18% reported experience with operating the robotic console. More senior residents (PGY3 and above) were involved in robotic cases compared with junior residents (78% vs 48%, p < 0.001). Overall, 60% of residents indicated that they received no prior education or training before their first robotic case. Approximately 64% of residents reported that formal training in robotic surgery was important in residency training and 46% of residents indicated that robotic-assisted cases interfered with resident learning. Only 11% felt that robotic-assisted cases would replace conventional laparoscopic surgery in the future. This study illustrates that although the most residents have a robot at their institution and have participated in robotic surgery cases, very few residents received formal training before participating in a robotic case. Copyright © 2014 Association of Program Directors in Surgery. Published by Elsevier Inc. All rights reserved.

Customized Interactive Robotic Treatment for Stroke: EMG-Triggered Therapy

PubMed Central

Dipietro, Laura; Ferraro, Mark; Palazzolo, Jerome Joseph; Krebs, Hermano Igo; Volpe, Bruce T.; Hogan, Neville

2009-01-01

A system for electromyographic (EMG) triggering of robot-assisted therapy (dubbed the EMG game) for stroke patients is presented. The onset of a patient’s attempt to move is detected by monitoring EMG in selected muscles, whereupon the robot assists her or him to perform point-to-point movements in a horizontal plane. Besides delivering customized robot-assisted therapy, the system can record signals that may be useful to better understand the process of recovery from stroke. Preliminary experiments aimed at testing the proposed system and gaining insight into the potential of EMG-triggered, robot-assisted therapy are reported. PMID:16200756

Impact of splenic hilar lymph node metastasis on prognosis in patients with advanced gastric cancer.

PubMed

Son, Taeil; Kwon, In Gyu; Lee, Joong Ho; Choi, Youn Young; Kim, Hyoung-Il; Cheong, Jae-Ho; Noh, Sung Hoon; Hyung, Woo Jin

2017-10-13

Impact of splenic hilar LN dissection during total gastrectomy for proximal advanced gastric cancer is controversial. The objective of this study was to assess the impact on prognosis of splenic hilar lymph node(LN) metastasis compared to that of metastasis to other regional LN groups. Patients who underwent total gastrectomy with D2 LN dissection from 2000 to 2010 were reviewed retrospectively. The clinicopathologic characteristics and long-term results of patients with splenic hilar LN metastasis were compared to those of patients with only metastasis to other extraperigastric LNs (stations #8a, #9, #11, or #12a). To investigate the survival benefit of performing splenic hilar LN dissection, the estimated therapeutic index for the procedure was calculated by multiplying the incidence of metastases in the hilar region by the survival rates for individuals with nodal involvement in that region. Of 602 patients, 87(14.5%) had hilar LN metastasis. The 5-year overall and relapse-free survival rates for patients with hilar LN metastasis were 24.1% and 12.1%, respectively. These rates were similar to those for patients with metastasis to other extraperigastric LNs ( P > 0.05), with similar recurrence patterns. Overall survival in the hilar LN metastasis group was better than that for patients with distant metastasis( P < 0.05). The estimated therapeutic index of splenic hilar LN dissection was 3.5, which was similar to index values for LN dissection at other extraperigastric LNs. Dissection of splenic hilar LNs during total gastrectomy for advanced gastric cancer allows for a prognosis similar to that achieved with dissection of extraperigastric LNs.

Dragon grapple

NASA Image and Video Library

2012-10-10

ISS033-E-011151 (10 Oct. 2012) --- The SpaceX Dragon commercial cargo craft is grappled by the International Space Station’s Canadarm2 robotic arm. Working from the robotics workstation inside the seven-windowed Cupola, Japan Aerospace Exploration Agency astronaut Aki Hoshide, Expedition 33 flight engineer, with the assistance of NASA astronaut Sunita Williams, commander, captured Dragon at 6:56 a.m. (EDT) and used the robotic arm to berth Dragon to the Earth-facing port of the Harmony node Oct. 10, 2012. Dragon is scheduled to spend 18 days attached to the station. During that time, the crew will unload 882 pounds of crew supplies, science research and hardware from the cargo craft and reload it with 1,673 pounds of cargo for return to Earth. After Dragon’s mission at the station is completed, the crew will use Canadarm2 to detach Dragon from Harmony and release it for a splashdown about six hours later in the Pacific Ocean, 250 miles off the coast of southern California. Dragon launched atop a Falcon 9 rocket at 8:35 p.m. Oct. 7 from Cape Canaveral Air Force Station in Florida, beginning NASA's first contracted cargo delivery flight, designated SpaceX CRS-1, to the station.

Dragon grapple

NASA Image and Video Library

2012-10-10

ISS033-E-011160 (10 Oct. 2012) --- The SpaceX Dragon commercial cargo craft is grappled by the International Space Station’s Canadarm2 robotic arm. Working from the robotics workstation inside the seven-windowed Cupola, Japan Aerospace Exploration Agency astronaut Aki Hoshide, Expedition 33 flight engineer, with the assistance of NASA astronaut Sunita Williams, commander, captured Dragon at 6:56 a.m. (EDT) and used the robotic arm to berth Dragon to the Earth-facing port of the Harmony node Oct. 10, 2012. Dragon is scheduled to spend 18 days attached to the station. During that time, the crew will unload 882 pounds of crew supplies, science research and hardware from the cargo craft and reload it with 1,673 pounds of cargo for return to Earth. After Dragon’s mission at the station is completed, the crew will use Canadarm2 to detach Dragon from Harmony and release it for a splashdown about six hours later in the Pacific Ocean, 250 miles off the coast of southern California. Dragon launched atop a Falcon 9 rocket at 8:35 p.m. Oct. 7 from Cape Canaveral Air Force Station in Florida, beginning NASA's first contracted cargo delivery flight, designated SpaceX CRS-1, to the station.

Dragon grapple

NASA Image and Video Library

2012-10-10

ISS033-E-011146 (10 Oct. 2012) --- The SpaceX Dragon commercial cargo craft is grappled by the International Space Station’s Canadarm2 robotic arm. Working from the robotics workstation inside the seven-windowed Cupola, Japan Aerospace Exploration Agency astronaut Aki Hoshide, Expedition 33 flight engineer, with the assistance of NASA astronaut Sunita Williams, commander, captured Dragon at 6:56 a.m. (EDT) and used the robotic arm to berth Dragon to the Earth-facing port of the Harmony node Oct. 10, 2012. Dragon is scheduled to spend 18 days attached to the station. During that time, the crew will unload 882 pounds of crew supplies, science research and hardware from the cargo craft and reload it with 1,673 pounds of cargo for return to Earth. After Dragon’s mission at the station is completed, the crew will use Canadarm2 to detach Dragon from Harmony and release it for a splashdown about six hours later in the Pacific Ocean, 250 miles off the coast of southern California. Dragon launched atop a Falcon 9 rocket at 8:35 p.m. Oct. 7 from Cape Canaveral Air Force Station in Florida, beginning NASA's first contracted cargo delivery flight, designated SpaceX CRS-1, to the station.

Robot-assisted walking with the Lokomat: the influence of different levels of guidance force on thorax and pelvis kinematics.

PubMed

Swinnen, Eva; Baeyens, Jean-Pierre; Knaepen, Kristel; Michielsen, Marc; Clijsen, Ron; Beckwée, David; Kerckhofs, Eric

2015-03-01

Little attention has been devoted to the thorax and pelvis movements during gait. The aim of this study is to compare differences in the thorax and pelvis kinematics during unassisted walking on a treadmill and during walking with robot assistance (Lokomat-system (Hocoma, Volketswil, Switzerland)). 18 healthy persons walked on a treadmill with and without the Lokomat system at 2kmph. Three different conditions of guidance force (30%, 60% and 100%) were used during robot-assisted treadmill walking (30% body weight support). The maximal movement amplitudes of the thorax and pelvis were measured (Polhemus Liberty™ (Polhemus, Colchester, Vermont, USA) (240/16)). A repeated measurement ANOVA was conducted. Robot-assisted treadmill walking with different levels of guidance force showed significantly smaller maximal movement amplitudes for thorax and pelvis, compared to treadmill walking. Only the antero-posterior tilting of the pelvis was significantly increased during robot-assisted treadmill walking compared to treadmill walking. No significant changes of kinematic parameters were found between the different levels of guidance force. With regard to the thorax and pelvis movements, robot-assisted treadmill walking is significantly different compared to treadmill walking. It can be concluded that when using robot assistance, the thorax is stimulated in a different way than during walking without robot assistance, influencing the balance training during gait. Copyright © 2015 Elsevier Ltd. All rights reserved.

Prospective evaluation of short-term impact and recovery of health related quality of life in men undergoing robotic assisted laparoscopic radical prostatectomy versus open radical prostatectomy.

PubMed

Miller, Javier; Smith, Angela; Kouba, Erik; Wallen, Eric; Pruthi, Raj S

2007-09-01

In the last few years there have been increasing claims that robotic assisted laparoscopic radical prostatectomy decreases short-term morbidity in patients undergoing surgical treatment for prostate cancer. However, there is surprisingly little objective evidence to support this point, which is often used to market the procedure to patients. To address this issue we prospectively evaluated patients undergoing open and robotic assisted laparoscopic radical prostatectomy at baseline and weekly through the postoperative period using a validated questionnaire. A total of 162 men undergoing radical prostatectomy, including open radical prostatectomy in 120 and robotic assisted laparoscopic radical prostatectomy in 42, for clinically localized prostate cancer completed the SF-12, version 2 Physical and Mental Health Survey Acute Form preoperatively and each week postoperatively for 6 weeks. Physical and Mental Component Scores were calculated from the questionnaires at each time point. Comparisons between the 2 surgical approaches were made at each time point. No significant differences were seen between the open and robotic assisted laparoscopic radical prostatectomy groups with regard to patient age, clinical stage or preoperative prostate specific antigen. Mean surgical blood loss was significantly higher in the open group compared to that in the robotic assisted laparoscopic group. Physical Component Scores in the robotic assisted laparoscopic group were significantly higher than those in the open cohort beginning postoperative week 1 and extending through week 6. On statistical extrapolation Physical Component Scores returned to baseline between weeks 5 and 6 postoperatively in the robotic assisted laparoscopic group and between weeks 6 and 7 in the open group. Mental Component Score scores were not statistically different between the groups except preoperatively. This study helps prospectively define short-term health related quality of life in patients undergoing robotic assisted laparoscopic vs open radical prostatectomy. Higher physical scores were seen in the robotic assisted laparoscopic group than the open group beginning postoperative week 1 and continuing weekly throughout the 6-week study period. Physical Component Score scores returned to baseline sooner in the robotic assisted laparoscopic group than in the open group.

Robot-assisted versus open radical prostatectomy: the differential effect of regionalization, procedure volume and operative approach.

PubMed

Sammon, Jesse D; Karakiewicz, Pierre I; Sun, Maxine; Sukumar, Shyam; Ravi, Praful; Ghani, Khurshid R; Bianchi, Marco; Peabody, James O; Shariat, Shahrokh F; Perrotte, Paul; Hu, Jim C; Menon, Mani; Trinh, Quoc-Dien

2013-04-01

The use of robot-assisted radical prostatectomy has increased rapidly despite the absence of randomized, controlled trials showing the superiority of this approach. While recent studies suggest an advantage for perioperative complication rates, they fail to account for the volume-outcome relationship. We compared perioperative outcomes after robot-assisted and open radical prostatectomy, while considering the impact of this established relationship. Using the NIS (Nationwide Inpatient Sample), we abstracted data on patients treated with radical prostatectomy in 2009. Univariable and multivariable logistic regression analyses were done to compare the rates of blood transfusion, intraoperative and postoperative complications, prolonged length of stay, increased hospital charges and mortality between robot-assisted and open radical prostatectomy overall and across volume quartiles. An estimated 77,616 men underwent radical prostatectomy, including a robot-assisted and an open procedure in 63.9% and 36.1%, respectively. Low volume centers averaged 26.2 robot-assisted and 5.2 open cases, while very high volume centers averaged 578.8 robot-assisted and 150.2 open cases. Overall, patients treated with the robot-assisted procedure experienced a lower rate of adverse outcomes than those treated with the open procedure for all measured categories. Across equivalent volume quartiles robot-assisted radical prostatectomy outcomes were generally favorable. However, the open procedure at high volume centers resulted in a lower postoperative complication rate (OR 0.59, 95% CI 0.46-0.75), elevated hospital charges (OR 0.75, 95% CI 0.64-0.87) and a comparable blood transfusion rate (OR 1.38, 95% CI 0.93-2.02) relative to the robot-assisted procedure at low volume centers. Regionalization has occurred to a greater extent for robot-assisted than for open radical prostatectomy with an associated benefit in overall outcomes. Nonetheless, low volume institutions experienced inferior outcomes relative to the highest volume centers irrespective of approach. These findings demonstrate the importance of accounting for hospital volume when examining the benefit of a surgical technique. Copyright © 2013 American Urological Association Education and Research, Inc. Published by Elsevier Inc. All rights reserved.

Human-robot cooperative movement training: learning a novel sensory motor transformation during walking with robotic assistance-as-needed.

PubMed

Emken, Jeremy L; Benitez, Raul; Reinkensmeyer, David J

2007-03-28

A prevailing paradigm of physical rehabilitation following neurologic injury is to "assist-as-needed" in completing desired movements. Several research groups are attempting to automate this principle with robotic movement training devices and patient cooperative algorithms that encourage voluntary participation. These attempts are currently not based on computational models of motor learning. Here we assume that motor recovery from a neurologic injury can be modelled as a process of learning a novel sensory motor transformation, which allows us to study a simplified experimental protocol amenable to mathematical description. Specifically, we use a robotic force field paradigm to impose a virtual impairment on the left leg of unimpaired subjects walking on a treadmill. We then derive an "assist-as-needed" robotic training algorithm to help subjects overcome the virtual impairment and walk normally. The problem is posed as an optimization of performance error and robotic assistance. The optimal robotic movement trainer becomes an error-based controller with a forgetting factor that bounds kinematic errors while systematically reducing its assistance when those errors are small. As humans have a natural range of movement variability, we introduce an error weighting function that causes the robotic trainer to disregard this variability. We experimentally validated the controller with ten unimpaired subjects by demonstrating how it helped the subjects learn the novel sensory motor transformation necessary to counteract the virtual impairment, while also preventing them from experiencing large kinematic errors. The addition of the error weighting function allowed the robot assistance to fade to zero even though the subjects' movements were variable. We also show that in order to assist-as-needed, the robot must relax its assistance at a rate faster than that of the learning human. The assist-as-needed algorithm proposed here can limit error during the learning of a dynamic motor task. The algorithm encourages learning by decreasing its assistance as a function of the ongoing progression of movement error. This type of algorithm is well suited for helping people learn dynamic tasks for which large kinematic errors are dangerous or discouraging, and thus may prove useful for robot-assisted movement training of walking or reaching following neurologic injury.

[Key vessels assessment and operation highlights in laparoscopic extended right hemicolectomy].

PubMed

Wang, Hao; Zhao, Quanquan

2018-03-25

Laparoscopic radical colectomies have been more widely used gradually, among which laparoscopic extended right hemicolectomy is considered as the most difficult procedure. The difficulty of extended right hemicolectomy lies in the need to dissect lymph nodes along the superior mesenteric vein (SMV) and disconnect numerous and possible aberrant vessels. To address this problem, we emphasize two points in key vessel assessment: getting familiar with the anatomy along the medial-to-lateral approach and having a good understanding about the preoperative imaging presentations. An accurately preoperative imaging assessment by abdominal enhanced CT can help the surgeon understand the relative position of the key vessels to be dealt with during operation and the situation of the possible aberrant vessels so as to guide the procedure more effectively and facilitate the prevention and management of the intraoperative complications. During operation, the operator should pay special attention to the management of the vessels in the ileocolic vessel region, Henle's trunk and middle colon vessels. The operation highlights of the key vessels are as follows: (1) The ileocolic vessels: identifying the Toldt's gap correctly and opening the vascular sheath of the SMV securely; making sure that the duodenum is well protected. (2) Henle's trunk: dissecting along the surface of the Henle's trunk; preserving the anterior superior pancreaticoduodenal vein (ASPDV) and main trunk of the Henle's trunk; disconnecting the roots of the right colic vein (RCV) and right gastroepiploic vein (RGEV), and then dissecting lymph nodes along the surface of the pancreas. (3) The middle colon vessels: identifying the root of the middle colon vessel along the lower edge of the pancreas; avoiding entering behind the pancreas; mobilizing the transverse mesocolon sufficiently along the surface of the pancreas. Finally, we discuss and analyze the disputes currently existing in laparoscopic extended right hemicolectomy, including dissection of No.6 lymph nodes, naking the SMA and dissecting lymph nodes around the roots of the branches of SMA. This article shares our experience about laparoscopic extended right hemicolectomy, hoping that it could help beginners master the technique more safely and skillfully.

The use of multiple time point dynamic positron emission tomography/computed tomography in patients with oral/head and neck cancer does not predictably identify metastatic cervical lymph nodes.

PubMed

Carlson, Eric R; Schaefferkoetter, Josh; Townsend, David; McCoy, J Michael; Campbell, Paul D; Long, Misty

2013-01-01

To determine whether the time course of 18-fluorine fluorodeoxyglucose (18F-FDG) activity in multiple consecutively obtained 18F-FDG positron emission tomography (PET)/computed tomography (CT) scans predictably identifies metastatic cervical adenopathy in patients with oral/head and neck cancer. It is hypothesized that the activity will increase significantly over time only in those lymph nodes harboring metastatic cancer. A prospective cohort study was performed whereby patients with oral/head and neck cancer underwent consecutive imaging at 9 time points with PET/CT from 60 to 115 minutes after injection with (18)F-FDG. The primary predictor variable was the status of the lymph nodes based on dynamic PET/CT imaging. Metastatic lymph nodes were defined as those that showed an increase greater than or equal to 10% over the baseline standard uptake values. The primary outcome variable was the pathologic status of the lymph node. A total of 2,237 lymph nodes were evaluated histopathologically in the 83 neck dissections that were performed in 74 patients. A total of 119 lymph nodes were noted to have hypermetabolic activity on the 90-minute (static) portion of the study and were able to be assessed by time points. When we compared the PET/CT time point (dynamic) data with the histopathologic analysis of the lymph nodes, the sensitivity, specificity, positive predictive value, negative predictive value, and accuracy were 60.3%, 70.5%, 66.0%, 65.2%, and 65.5%, respectively. The use of dynamic PET/CT imaging does not permit the ablative surgeon to depend only on the results of the PET/CT study to determine which patients will benefit from neck dissection. As such, we maintain that surgeons should continue to rely on clinical judgment and maintain a low threshold for executing neck dissection in patients with oral/head and neck cancer, including those patients with N0 neck designations. Copyright © 2013 American Association of Oral and Maxillofacial Surgeons. Published by Elsevier Inc. All rights reserved.

Thermochemoradiation Therapy Using Superselective Intra-arterial Infusion via Superficial Temporal and Occipital Arteries for Oral Cancer With N3 Cervical Lymph Node Metastases

DOE Office of Scientific and Technical Information (OSTI.GOV)

Mitsudo, Kenji, E-mail: mitsudo@yokohama-cu.ac.jp; Koizumi, Toshiyuki; Iida, Masaki

2012-08-01

Purpose: To evaluate the therapeutic results and histopathological effects of treatment with thermochemoradiation therapy using superselective intra-arterial infusion via the superficial temporal and occipital arteries for N3 cervical lymph node metastases of advanced oral cancer. Methods and Materials: Between April 2005 and September 2010, 9 patients with N3 cervical lymph node metastases of oral squamous cell carcinoma underwent thermochemoradiation therapy using superselective intra-arterial infusion with docetaxel (DOC) and cisplatin (CDDP). Treatment consisted of hyperthermia (2-8 sessions), superselective intra-arterial infusions (DOC, total 40-60 mg/m{sup 2}; CDDP, total 100-150 mg/m{sup 2}) and daily concurrent radiation therapy (total, 40-60 Gy) for 4-6 weeks.more » Results: Six of 9 patients underwent neck dissection 5-8 weeks after treatment. In four of these 6 patients, all metastatic lymph nodes, including those at N3, were grade 3 (non-viable tumor cells present) or grade 4 (no tumor cells present) tumors, as classified by the system by Shimosato et al (Shimosato et al Jpn J Clin Oncol 1971;1:19-35). In 2 of these 6 patients, the metastatic lymph nodes were grade 2b (destruction of tumor structures with a small amount of residual viable tumor cells). The other 3 patients did not undergo neck dissection due to distant metastasis after completion of thermochemoradiation therapy (n=2) and refusal (n=1). The patient who refused neck dissection underwent biopsy of the N3 lymph node and primary sites and showed grade 3 cancer. During follow-up, 5 patients were alive without disease, and 4 patients died due to pulmonary metastasis (n=3) and noncancer-related causes (n=1). Five-year survival and locoregional control rates were 51% and 88%, respectively. Conclusions: Thermochemoradiation therapy using intra-arterial infusion provided good histopathologic effects and locoregional control rates in patients with N3 metastatic lymph nodes. However, patients with N3 metastatic lymph nodes experienced a high rate of distant metastases.« less

Robot-assisted Surgery for Benign Ureteral Strictures: Experience and Outcomes from Four Tertiary Care Institutions.

PubMed

Buffi, Nicolò Maria; Lughezzani, Giovanni; Hurle, Rodolfo; Lazzeri, Massimo; Taverna, Gianluigi; Bozzini, Giorgio; Bertolo, Riccardo; Checcucci, Enrico; Porpiglia, Francesco; Fossati, Nicola; Gandaglia, Giorgio; Larcher, Alessandro; Suardi, Nazareno; Montorsi, Francesco; Lista, Giuliana; Guazzoni, Giorgio; Mottrie, Alexandre

2017-06-01

Minimally invasive treatment of benign ureteral strictures is still challenging because of its technical complexity. In this context, robot-assisted surgery may overcome the limits of the laparoscopic approach. To evaluate outcomes for robotic ureteral repair in a multi-institutional cohort of patients treated for ureteropelvic junction obstruction and ureteral stricture (US) at four tertiary referral centres. This retrospective study reports data for 183 patients treated with standard robot-assisted pyeloplasty (PYP) and robotic uretero-ureterostomy (UUY) at four high-volume centres from January 2006 to September 2014. Robotic PYP and robot-assisted UUY were performed according to previously reported surgical techniques. Preoperative, intraoperative, and postoperative variables and outcomes were assessed. A descriptive statistical analysis was performed. No robot-assisted UUY cases required surgical conversion, while 2.8% of PYP cases were not completed robotically. The median operative time was 120 and 150min for robot-assisted PYP and robot-assisted UUY, respectively. No intraoperative complications were reported. The overall complication rate for all procedures was 11% (n=20) and complications were mostly of low grade. The high-grade complication rate was 2.2% (n=4). At median follow-up of 24 mo, the overall success rate was >90% for both procedures. The study limitations include its retrospective nature and the heterogeneity of the study population. Robotic surgery for benign US is safe and effective, with limited risk of high-grade complications and good intermediate-term results. In this study we review the use of robotic surgery at four different tertiary care centres in the treatment of patients affected by benign ureteral strictures. Our results demonstrate that robotic surgery is a safe alternative to the standard open approach in the treatment of ureteral strictures. Copyright © 2016 European Association of Urology. Published by Elsevier B.V. All rights reserved.

Robot-Assisted Thoracic Surgery (RATS): Perioperative Nursing Professional Development Program.

PubMed

Sarmanian, Julie D

2015-09-01

Robot-assisted surgery continues to grow in popularity worldwide. Competency and training of personnel for robot-assisted thoracic surgery (RATS) is less established compared with other robot-assisted specialties. Major differences between minimally invasive approaches to thoracic surgery (eg, video-assisted thoracoscopic surgery) and RATS are presented to address a paucity of literature on the subject. Although perioperative nursing considerations are universal to all robot-assisted procedures, there are nursing consideration specific to RATS. This article provides a RATS perioperative nursing development program for RN circulators and scrub personnel. Development of perioperative nursing knowledge and skills through implementation of targeted training programs enables nurses to provide a safe surgical experience for patients undergoing RATS. Copyright © 2015 AORN, Inc. Published by Elsevier Inc. All rights reserved.

Comparison of systematic mediastinal lymph node dissection versus systematic sampling for lung cancer staging and completeness of surgery.

PubMed

Wu, Nan; Yan, Shi; Lv, Chao; Feng, Yuan; Wang, Yuzhao; Zhang, Lijian; Yang, Yue

2011-12-01

This self-controlled prospective study was designed to investigate the efficacy of systematic sampling (SS), compared with systematic mediastinal lymph node dissection (SMLD), for pathologic staging and completeness of surgery. Over a period of 11 mo, 110 patients with lung cancer were enlisted and treated by pulmonary resection. Surgeons systematically sampled mediastinal lymph nodes prior to pulmonary resection, and after pulmonary resection SMLD was performed to each patient using Mountain's procedure [1]. After SMLD, pN status was classified as N0 in 57 cases, N1 in 27, and N2 in 26. SS detected 38.3% of pooled nodes and 37.6% of pooled positive nodes collected from SMLD. Pathologic diagnosis after SS was understaged in nine cases (8.2%) compared with staging after SMLD. However, surgery was incomplete in 24 cases (21.8%) if SMLD was not performed after sampling. Negative predictive value for SS was 86.8% on the right side, and 95.0% on the left. Three categories were generated according to pN status: negative nodes in SS and additional negative nodes from SMLD [S(-)D(-)], negative nodes in SS but additional positive nodes from SMLD [S(-)D(+)], and positive nodes in SS [S(+)D(+)]. cN2 (P=0.000) and CEA level (P=0.001) were correlated with pN status. There was significant overall survival difference between non-N2 group and N2 group (P=0.002). SMLD may harvest about three times of mediastinal lymph nodes compared with SS. SS is more likely to affect the completeness of surgery instead of underrating pathologic stage. Copyright © 2011 Elsevier Inc. All rights reserved.

Magnetic Resonance Lymphography Findings in Patients With Biochemical Recurrence After Prostatectomy and the Relation With the Stephenson Nomogram

DOE Office of Scientific and Technical Information (OSTI.GOV)

Meijer, Hanneke J.M., E-mail: H.Meijer@rther.umcn.nl; Debats, Oscar A.; Roach, Mack

2012-12-01

Purpose: To estimate the occurrence of positive lymph nodes on magnetic resonance lymphography (MRL) in patients with a prostate-specific antigen (PSA) recurrence after prostatectomy and to investigate the relation between score on the Stephenson nomogram and lymph node involvement on MRL. Methods and Materials: Sixty-five candidates for salvage radiation therapy were referred for an MRL to determine their lymph node status. Clinical and histopathologic features were recorded. For 49 patients, data were complete to calculate the Stephenson nomogram score. Receiver operating characteristic (ROC) analysis was performed to determine how well this nomogram related to the MRL result. Analysis was donemore » for the whole group and separately for patients with a PSA <1.0 ng/mL to determine the situation in candidates for early salvage radiation therapy, and for patients without pathologic lymph nodes at initial lymph node dissection. Results: MRL detected positive lymph nodes in 47 patients. ROC analysis for the Stephenson nomogram yielded an area under the curve (AUC) of 0.78 (95% confidence interval, 0.61-0.93). Of 29 patients with a PSA <1.0 ng/mL, 18 had a positive MRL. Of 37 patients without lymph node involvement at initial lymph node dissection, 25 had a positive MRL. ROC analysis for the Stephenson nomogram showed AUCs of 0.84 and 0.74, respectively, for these latter groups. Conclusion: MRL detected positive lymph nodes in 72% of candidates for salvage radiation therapy, in 62% of candidates for early salvage radiation therapy, and in 68% of initially node-negative patients. The Stephenson nomogram showed a good correlation with the MRL result and may thus be useful for identifying patients with a PSA recurrence who are at high risk for lymph node involvement.« less

Nomogram for prediction of level 2 axillary lymph node metastasis in proven level 1 node-positive breast cancer patients.

PubMed

Jiang, Yanlin; Xu, Hong; Zhang, Hao; Ou, Xunyan; Xu, Zhen; Ai, Liping; Sun, Lisha; Liu, Caigang

2017-09-22

The current management of the axilla in level 1 node-positive breast cancer patients is axillary lymph node dissection regardless of the status of the level 2 axillary lymph nodes. The goal of this study was to develop a nomogram predicting the probability of level 2 axillary lymph node metastasis (L-2-ALNM) in patients with level 1 axillary node-positive breast cancer. We reviewed the records of 974 patients with pathology-confirmed level 1 node-positive breast cancer between 2010 and 2014 at the Liaoning Cancer Hospital and Institute. The patients were randomized 1:1 and divided into a modeling group and a validation group. Clinical and pathological features of the patients were assessed with uni- and multivariate logistic regression. A nomogram based on independent predictors for the L-2-ALNM identified by multivariate logistic regression was constructed. Independent predictors of L-2-ALNM by the multivariate logistic regression analysis included tumor size, Ki-67 status, histological grade, and number of positive level 1 axillary lymph nodes. The areas under the receiver operating characteristic curve of the modeling set and the validation set were 0.828 and 0.816, respectively. The false-negative rates of the L-2-ALNM nomogram were 1.82% and 7.41% for the predicted probability cut-off points of < 6% and < 10%, respectively, when applied to the validation group. Our nomogram could help predict L-2-ALNM in patients with level 1 axillary lymph node metastasis. Patients with a low probability of L-2-ALNM could be spared level 2 axillary lymph node dissection, thereby reducing postoperative morbidity.

Adaptive model-based assistive control for pneumatic direct driven soft rehabilitation robots.

PubMed

Wilkening, Andre; Ivlev, Oleg

2013-06-01

Assistive behavior and inherent compliance are assumed to be the essential properties for effective robot-assisted therapy in neurological as well as in orthopedic rehabilitation. This paper presents two adaptive model-based assistive controllers for pneumatic direct driven soft rehabilitation robots that are based on separated models of the soft-robot and the patient's extremity, in order to take into account the individual patient's behavior, effort and ability during control, what is assumed to be essential to relearn lost motor functions in neurological and facilitate muscle reconstruction in orthopedic rehabilitation. The high inherent compliance of soft-actuators allows for a general human-robot interaction and provides the base for effective and dependable assistive control. An inverse model of the soft-robot with estimated parameters is used to achieve robot transparency during treatment and inverse adaptive models of the individual patient's extremity allow the controllers to learn on-line the individual patient's behavior and effort and react in a way that assist the patient only as much as needed. The effectiveness of the controllers is evaluated with unimpaired subjects using a first prototype of a soft-robot for elbow training. Advantages and disadvantages of both controllers are analyzed and discussed.

Adaptive Control Parameters for Dispersal of Multi-Agent Mobile Ad Hoc Network (MANET) Swarms

DOE Office of Scientific and Technical Information (OSTI.GOV)

Kurt Derr; Milos Manic

A mobile ad hoc network is a collection of independent nodes that communicate wirelessly with one another. This paper investigates nodes that are swarm robots with communications and sensing capabilities. Each robot in the swarm may operate in a distributed and decentralized manner to achieve some goal. This paper presents a novel approach to dynamically adapting control parameters to achieve mesh configuration stability. The presented approach to robot interaction is based on spring force laws (attraction and repulsion laws) to create near-optimal mesh like configurations. In prior work, we presented the extended virtual spring mesh (EVSM) algorithm for the dispersionmore » of robot swarms. This paper extends the EVSM framework by providing the first known study on the effects of adaptive versus static control parameters on robot swarm stability. The EVSM algorithm provides the following novelties: 1) improved performance with adaptive control parameters and 2) accelerated convergence with high formation effectiveness. Simulation results show that 120 robots reach convergence using adaptive control parameters more than twice as fast as with static control parameters in a multiple obstacle environment.« less

Cervical lymph node metastases in squamous cell carcinoma of tongue and floor of mouth.

PubMed

Ehsan-ul-Haq, Muhammad; Warraich, Riaz Ahmed; Abid, Hina; Sajid, Malik Ali Hassan

2011-01-01

Oral squamous cell carcinoma has high chances of cervical lymph node metastasis. This case series describes the distribution of cervical lymph nodes in 50 cases of squamous cell carcinoma of tongue and floor of mouth. The mean age was 47.28±10.5 years. Thirty positive metastatic lymph nodes were found; 90% occurring at level I-II mostly in T4 size but also in T1 and T2 cases. The distribution of involved lymph nodes in oral cancer affects the neck dissection extent and is, therefore, an important pre-operative feature.

A prospective single-center study of sentinel lymph node detection in cervical carcinoma: is there a place in clinical practice?

PubMed

Devaja, Omer; Mehra, Gautam; Coutts, Michael; Montalto, Stephen Attard; Donaldson, John; Kodampur, Mallikarjun; Papadopoulos, Andreas John

2012-07-01

To establish the accuracy of sentinel lymph node (SLN) detection in early cervical cancer. Sentinel lymph node detection was performed prospectively over a 6-year period in 86 women undergoing surgery for cervical carcinoma by the combined method (Tc-99m and methylene blue dye). Further ultrastaging was performed on a subgroup of 26 patients who had benign SLNs on initial routine histological examination. The SLN was detected in 84 (97.7%) of 86 women by the combined method. Blue dye uptake was not seen in 8 women (90.7%). Sentinel lymph nodes were detected bilaterally in 63 women (73.3%), and the external iliac region was the most common anatomic location (48.8%). The median SLN count was 3 nodes (range, 1-7). Of the 84 women with sentinel node detection, 65 also underwent bilateral pelvic lymph node dissection, and in none of these cases was a benign SLN associated with a malignant non-SLN (100% negative predictive value). The median non-SLN count for all patients was 19 nodes (range, 8-35). Eighteen patients underwent removal of the SLN without bilateral pelvic lymph node dissection. Nine women (10.5%) had positive lymph nodes on final histology. One patient had bulky pelvic nodes on preoperative imaging and underwent removal of the negative bulky malignant lymph nodes and a benign SLN on the contralateral side. This latter case confirms the unreliability of the SLN method with bulky nodes. The remaining 8 patients had positive SLNs with negative nonsentinel lymph nodes. Fifty-nine SLNs from 26 patients, which were benign on initial routine histology, underwent ultrastaging, but no further disease was identified. Four patients (5%) relapsed after a median follow-up of 28 months (range, 8-80 months). Sentinel lymph node detection is an accurate and safe method in the assessment of nodal status in early cervical carcinoma.

Robotic-Assisted Thoracic Surgery for Early-Stage Lung Cancer: A Review.

PubMed

Brooks, Paula

2015-07-01

This review evaluates the benefits and disadvantages associated with the use of robotic-assisted technology in performing lobectomies in patients with early-stage lung cancer. The author conducted a literature search of Ovid®, MEDLINE®, PubMed®, and CINAHL® for articles published from 2005 to 2013. Search criteria included key terms such as robot, robotic, robotic-assisted lobectomy, and lung cancer. Of 922 articles, the author included a total of 12 research-based published studies in the analysis and incorporated the findings into an evidence table. Results showed that robotic-assisted lobectomies are feasible safe procedures for patients with stage 1A or 1B lung cancer; however, there is a steep learning curve and long-term randomized studies evaluating robotic-assisted lobectomy and conventional posterolateral thoracotomy or video-assisted thoracic lobectomy are needed. For patient safety, perioperative nurses should be aware of the length of time and experience required to perform these procedures, the costs, techniques, benefits, and disadvantages. Copyright © 2015 AORN, Inc. Published by Elsevier Inc. All rights reserved.

Does robotic assistance confer an economic benefit during laparoscopic radical nephrectomy?

PubMed

Yang, David Y; Monn, M Francesca; Bahler, Clinton D; Sundaram, Chandru P

2014-09-01

While robotic assisted radical nephrectomy is safe with outcomes and complication rates comparable to those of the pure laparoscopic approach, there is little evidence of an economic or clinical benefit. From the 2009 to 2011 Nationwide Inpatient Sample database we identified patients 18 years old or older who underwent radical nephrectomy for primary renal malignancy. Robotic assisted and laparoscopic techniques were noted. Patients treated with the open technique and those with evidence of metastatic disease were excluded from analysis. Descriptive statistics were performed using the chi-square and Mann-Whitney tests, and the Student t-test. Multiple linear regression was done to examine factors associated with increased hospital costs and charges. We identified 24,312 radical nephrectomy cases for study inclusion, of which 7,787 (32%) were performed robotically. There was no demographic difference between robotic assisted and pure laparoscopic radical nephrectomy cases. Median total charges were $47,036 vs $38,068 for robotic assisted vs laparoscopic surgery (p <0.001). Median total hospital costs for robotic assisted surgery were $15,149 compared to $11,735 for laparoscopic surgery (p <0.001). There was no difference in perioperative complications or the incidence of death. Compared to the laparoscopic approach robotic assistance conferred an estimated $4,565 and $11,267 increase in hospital costs and charges, respectively, when adjusted for adapted Charlson comorbidity index score, perioperative complications and length of stay (p <0.001). Robotic assisted radical nephrectomy results in increased medical expense without improving patient morbidity. Assuming surgeon proficiency with pure laparoscopy, robotic technology should be reserved primarily for complex surgeries requiring reconstruction. Traditional laparoscopic techniques should continue to be used for routine radical nephrectomy. Copyright © 2014 American Urological Association Education and Research, Inc. Published by Elsevier Inc. All rights reserved.

Management of early colonic neoplasia: where are we now and where are we heading?

PubMed

Longcroft-Wheaton, Gaius; Bhandari, Pradeep

2017-03-01

There have been considerable advances in the endoscopic treatment of colorectal neoplasia. The development of endoscopic submucosal dissection and full thickness resection techniques is changing the way benign disease and early cancers are managed. This article reviews the evidence behind these new techniques and discusses where this field is likely to move in the future. Areas covered: A PubMed literature review of resection techniques for colonic neoplasia was performed. The clinical and cost effectiveness of endoscopic mucosal resection (EMR) is examined. The development of endoscopic submucosal dissection (ESD) and knife assisted resection is described and issues around training reviewed. Efficacy is compared to both EMR and transanal endoscopic microsurgery. The future is considered, including full thickness resection techniques and robotic endoscopy. Expert commentary: The perceived barriers to ESD are falling, and views that such techniques are only possible in Japan are disappearing. The key barriers to uptake will be training, and the development of educational programmes should be seen as a priority. The debate between TEMS and ESD will continue, but ESD is more flexible and cheaper. This will become less significant as the number of endoscopists trained in ESD grows and some TEMS surgeons may shift across towards ESD.

Occult Nodal Disease Prevalence and Distribution in Recurrent Laryngeal Cancer Requiring Salvage Laryngectomy.

PubMed

Birkeland, Andrew C; Rosko, Andrew J; Issa, Mohamad R; Shuman, Andrew G; Prince, Mark E; Wolf, Gregory T; Bradford, Carol R; McHugh, Jonathan B; Brenner, J Chad; Spector, Matthew E

2016-03-01

The indications for neck dissection concurrent with salvage laryngectomy in the clinically N0 setting remain unclear. Our goals were to determine the prevalence of occult nodal disease, analyze nodal disease distribution patterns, and identify predictors of occult nodal disease in a salvage laryngectomy cohort. Case series with planned data collection. Tertiary academic center. Patients with persistent or recurrent laryngeal squamous cell carcinoma (LSCC) after radiation/chemoradiation failure undergoing salvage laryngectomy with neck dissection. We analyzed a single-institution retrospective case series of patients between 1997 and 2014 and identified those who had clinically N0 (cN0) necks (n = 203). Clinical and pathologic data, including nodal prevalence and distribution, were collected and statistical analyses performed. Overall, cN0 necks had histologically positive occult nodes in 17% (n = 35) of cases. Univariate predictors of occult nodal positivity included recurrent T4 stage (34% T4 vs 12% non-T4; P = .0003) and supraglottic subsite (28% supraglottic vs 10% nonsupraglottic; P = .0006). Histologically positive nodes associated with supraglottic primaries were most frequently positive in ipsilateral levels II and III (17% and 16%). Positive nodes for glottic LSCC were most frequently positive in the ipsilateral and contralateral paratracheal nodes (11% and 9%). Histologically positive occult nodes are identified in 17% of cN0 patients undergoing salvage laryngectomy with neck dissection. Occult nodal disease varies in frequency and distribution based on tumor subsite. Predictors of high (>20%) occult nodal positivity include T4 tumors and supraglottic subsite. In glottic LSCC, the most frequent sites of occult nodal disease are the paratracheal nodal basins. © American Academy of Otolaryngology—Head and Neck Surgery Foundation 2016.

The role of lymphadenectomy in endometrial cancer: was the ASTEC trial doomed by design and are we destined to repeat that mistake?

PubMed

Naumann, R Wendel

2012-07-01

This study examines the design of previous and future trials of lymph node dissection in endometrial cancer. Data from previous trials were used to construct a decision analysis modeling the risk of lymphatic spread and the effects of treatment on patients with endometrial cancer. This model was then applied to previous trials as well as other future trial designs that might be used to address this subject. Comparing the predicted and actual results in the ASTEC trial, the model closely mimics the survival results with and without lymph node dissection for the low and high risk groups. The model suggests a survival difference of less than 2% between the experimental and control arms of the ASTEC trial under all circumstances. Sensitivity analyses reveal that these conclusions are robust. Future trial designs were also modeled with hysterectomy only, hysterectomy with radiation in intermediate risk patients, and staging with radiation only with node positive patients. Predicted outcomes for these approaches yield survival rates of 88%, 90%, and 93% in clinical stage I patients who have a risk of pelvic node involvement of approximately 7%. These estimates were 78%, 82%, and 89% in intermediate risk patients who have a risk of nodal spread of approximately 15%. This model accurately predicts the outcome of previous trials and demonstrates that even if lymph node dissection was therapeutic, these trials would have been negative due to study design. Furthermore, future trial designs that are being considered would need to be conducted in high-intermediate risk patients to detect any difference. Copyright © 2012 Elsevier Inc. All rights reserved.

Technical feasibility of laparoscopic total gastrectomy with splenectomy for gastric cancer: clinical short-term and long-term outcomes.

PubMed

Nakata, Kohei; Nagai, Eishi; Ohuchida, Kenoki; Shimizu, Shuji; Tanaka, Masao

2015-07-01

Since its widespread acceptance for the treatment of early gastric cancer, laparoscopic gastrectomy has been gaining popularity as a treatment option for advanced gastric cancer. However, laparoscopic total gastrectomy (LTG) with splenectomy is seldom performed, because of its difficulty of removal of station 10 lymph nodes; splenectomy is technically essential for complete removal of these lymph nodes. The purpose of this study was to describe the details of the LTG procedure and to evaluate the short- and long-term outcomes of LTG with splenectomy. Of 725 consecutive patients with gastric cancer who underwent laparoscopic gastrectomy with lymph node dissection in our institution from January 1996 to December 2012, 18 consecutive patients who underwent LTG with splenectomy were enrolled in this study. No operative mortality occurred, and the pathological margins were free from cancer cells in all patients. The mean operation time was 388 min (range 324-566 min). The mean volume of blood loss was 45 ml (range 5-347 ml), and the mean number of dissected lymph nodes was 51 (range 40-105). Postoperative morbidity occurred in six patients (33.3%) (each with grade B postoperative pancreatic fistula, postoperative bleeding, chylous ascites, atelectasis, ileus, and intra-abdominal infection). Five patients (27.8%) developed recurrence (four in the peritoneum and one in the liver), and the overall 3- and 5-year survival rates were 83.0 and 72.6%, respectively. Considering the 0% mortality rate and low rates of postoperative morbidity and locoregional recurrence, LTG with splenectomy is technically and oncologically acceptable. This procedure can be expanded to include advanced gastric cancer, which generally requires splenectomy for lymph node dissection.

Acceptance and perceived usefulness of robots to assist with activities of daily living and healthcare tasks.

PubMed

Hall, Amanda K; Backonja, Uba; Painter, Ian; Cakmak, Maya; Sung, Minjung; Lau, Timothy; Thompson, Hilaire J; Demiris, George

2017-11-29

As the number of older adults living with chronic conditions continues to rise, they will require assistance with activities of daily living (ADL) and healthcare tasks to continue living independently in their homes. One proposed solution to assist with the care needs of an aging population and a shrinking healthcare workforce is robotic technology. Using a cross-sectional survey design, we purposively sampled adults (≥18 years old) to assess generational acceptance and perceived usefulness of robots to assist with ADLs, healthcare tasks, and evaluate acceptance of robotic healthcare assistance across different settings. A total of 499 adults (age range [years] 18-98, Mean = 38.7, SD = 22.7) responded to the survey. Significant differences were found among young, middle-aged, and older adults on perceived usefulness of robots for cleaning, escorting them around town, acting as companionship, delivering meals, assessing sadness and calling for help, providing medical advice, taking vital sign assessments, and assisting with personal care (p < 0.05). The majority of younger adults reported that they would like a robot to provide healthcare assistance in the hospital, compared to middle-aged and older adults (p < 0.001). Results of this study can guide the design of robots to assist adults of all ages with useful tasks.

Robotic assisted excision of a left ventricular myxoma.

PubMed

Hassan, Mohammed; Smith, J Michael

2012-01-01

We present a rare case of left ventricular myxoma discovered incidentally in an asymptomatic 16-year old male. The patient underwent the appropriate work-up and a robotic-assisted excision of the mass. The patient had an uneventful recovery and was discharged home at postoperative day 3. To our knowledge, this is the first case of robotic-assisted left ventricular myxoma excision in the literature. Robotic-assisted surgery of left ventricular myxomas is a safe and feasible method of excision.

Surgical strategy for the treatment of sporadic medullary thyroid carcinoma: our experience.

PubMed

Lupone, G; Antonino, A; Rosato, A; Zenone, P; Iervolino, E M; Grillo, M; De Palma, M

2012-01-01

Medullary thyroid carcinoma (MTC) is a rare disease which accounts for approximately 5-9% of all thyroid cancers and originates from the calcitonin-screening parafollicular C cells. MTC can be divided into two subgroups: sporadic (75%) or inherited (25%). The majority of patients with invasive MTC have metastasis to regional lymph nodes at the time of diagnosis, as evidenced by the frequent finding of persistently elevated calcitonin levels after thyroidectomy and the high rates of recurrence in the cervical lymph nodes reported in retrospective studies. The purpose of the study is to review our single institution's experience with MTC since 1998 and to evaluate surgical strategy, patterns of lymph node metastases and calcitonin response to compartment-oriented lymphadenectomy in patients with primary or recurrent sporadic medullary thyroid carcinoma. A retrospective review of 26 patients treated for MTC at the "Antonio Cardarelli" Hospital referral center, in Naples, between 1998 and 2012. There were 18 female and 8 male patients, median age at presentation was 55 years, and median follow-up for survivors was 5 years. Total thyroidectomy was performed in all 26 patients; central compartment (CC) node dissection (level VI) in 12 (46%) patients; central plus lateral compartment (LC) node dissection (levels II, III, and IV) in 7 (27%) patients. 4 patients (15%) underwent reoperation for loco-regional recurrent/persistent MTC. Results. After a median post-surgical follow-up of 5 years (range 1-10 years), 63 % of patients were living disease-free, 15% were living with disease and/or persistently elevated calcitonin levels after surgery, 11% were deceased due to MTC and 11 % were lost to follow-up. We agree with most authors advocating for a total thyroidectomy and prophylactic central neck dissection in the setting of clinically detected MTC. Lateral neck dissection may be best reserved for patients with positive preoperative imaging. Nevertheless MTC has a high rate of lymph node metastases that are sub optimally detected preoperatively in the central compartment by neck ultrasound or intra-operatively by the surgeon, and reoperation is associated with a higher rate of surgical complications. In our limited experience, patients with thyroid confined nodular pathology, without nodal disease and unknown preoperative diagnosis of MTC, underwent only total thyroidectomy with a good prognosis.

Stewart Treves Syndrome.

PubMed

Pereira, Elisangela Samartin Pegas; Moraes, Elisa Trino de; Siqueira, Daniela Melo; Santos, Marcel Alex Soares dos

2015-01-01

Stewart-Treves Syndrome is characterized by the presence of lymphangiosarcoma on limb extremities. Rare, it occurs in 0.5% of patients who have undergone radical mastectomy with axillary node dissection. The main cause is chronic lymphedema with endothelial and lymphatic differentiation, with no direct relationship to breast cancer. Seven years after a radical right-side mastectomy with lymph node dissection and adjuvant therapy, the patient developed a lesion on her right arm. The dermatological examination revealed an erythematous nodule with bleeding surface on chronic right forearm lymphedema. After the biopsy, a lymphangiosarcoma on chronic lymphedema was diagnosed. Infrequent, this syndrome is relevant because of its associated mortality. Early diagnosis is important to improve survival and reduce complications.

Robot-assisted intersphincteric resection facilitates an efficient sphincter-saving in patients with low rectal cancer.

PubMed

Kim, Jin Cheon; Lee, Jong Lyul; Alotaibi, Abdulrahman Muaod; Yoon, Yong Sik; Kim, Chan Wook; Park, In Ja

2017-08-01

Few investigations of robot-assisted intersphincteric resection (ISR) are presently available to support this procedure as a safe and efficient procedure. We aimed to evaluate the utility of robot-assisted ISR by comparison between ISR and abdominoperineal resection (APR) using both robot-assisted and open approaches. The 558 patients with lower rectal cancer (LRC) who underwent curative operation was enrolled between July 2010 and June 2015 to perform either by robot-assisted (ISR vs. APR = 310 vs. 34) or open approaches (144 vs. 70). Perioperative and functional outcomes including urogenital and anorectal dysfunctions were measured. Recurrence and survival were examined in 216 patients in which >3 years had elapsed after the operation. The robot-assisted approach was the most significant parameter to determine ISR achievement among potent parameters (OR = 3.467, 95% CI = 2.095-5.738, p < 0.001). Early surgical complications occurred more frequently in the open ISR group (16 vs. 7.7%, p = 0.01). The voiding and male sexual dysfunctions were significantly more frequent in the open ISR (p < 0.05). The fecal incontinence and lifestyle alteration score was greater in the open ISR than in the robot-assisted ISR at 12 and 24 months, respectively (p < 0.05). However, the 3-year cumulative rates of local recurrence and survival did not differ between the two groups. The current procedure of robot-assisted ISR replaced a significant portion of APR to achieve successful SSO via mostly transabdominal approach and double-stapled anastomosis. The robot-assisted ISR with minimal invasiveness might be a help to reduce anorectal and urogenital dysfunctions.

A Comparison of Robotically Assisted Microsurgery versus Manual Microsurgery in Challenging Situations.

PubMed

Willems, Joost I P; Shin, Alexandra M; Shin, Delaney M; Bishop, Allen T; Shin, Alexander Y

2016-04-01

Microsurgery can be challenging secondary to orientation of the vessels, accessibility, or depth of the wound. Robotically assisted microsurgery reduces tremors and improves visualization and may improve the quality of anastomosis compared with traditional microsurgery. The purpose of this study was to compare robotically assisted microsurgery to traditional microsurgery in technically challenging situations with respect to time of anastomosis, quality of anastomosis, and Objective Structured Assessment of Technical Skills. Two investigators with no prior surgery or microsurgery experience performed 160 anastomoses on artificial microvessels after undergoing standardized traditional and robotically assisted microsurgery courses. Five different exposure groups were created with depths of 0, 10, and 20 cm and sidewall angles of 20 and 30 degrees. A comparison of 80 manual with 80 robotically assisted microsurgery anastomoses in different exposure groups was undertaken. The modified Objective Structured Assessment of Technical Skills scoring system, duration per anastomosis, and a subjective comfort scale were evaluated. In the most difficult exposure, Objective Structured Assessment of Technical Skills scores were similar in both groups (p = 0.98), the duration was higher in the manual group (p = 0.004), and the subjective comfort rating was higher in the robotically assisted microsurgery group (p < 0.001). In the easiest (0-cm depth, flat) exposure, Objective Structured Assessment of Technical Skills scores were higher in the manual group (p = 0.018) and the duration was longer in the robotically assisted microsurgery group (p = 0.008). Manual surgery was superior to robotically assisted microsurgery in technically easy exposures. In difficult exposures (greater depth and lower sidewall angles), however, robotically assisted microsurgery had a shorter surgery time and a higher comfort rating, with Objective Structured Assessment of Technical Skills scores similar to those assessing traditional microsurgery. Therapeutic, V.

Wireless intraoral tongue control of an assistive robotic arm for individuals with tetraplegia.

PubMed

Andreasen Struijk, Lotte N S; Egsgaard, Line Lindhardt; Lontis, Romulus; Gaihede, Michael; Bentsen, Bo

2017-11-06

For an individual with tetraplegia assistive robotic arms provide a potentially invaluable opportunity for rehabilitation. However, there is a lack of available control methods to allow these individuals to fully control the assistive arms. Here we show that it is possible for an individual with tetraplegia to use the tongue to fully control all 14 movements of an assistive robotic arm in a three dimensional space using a wireless intraoral control system, thus allowing for numerous activities of daily living. We developed a tongue-based robotic control method incorporating a multi-sensor inductive tongue interface. One abled-bodied individual and one individual with tetraplegia performed a proof of concept study by controlling the robot with their tongue using direct actuator control and endpoint control, respectively. After 30 min of training, the able-bodied experimental participant tongue controlled the assistive robot to pick up a roll of tape in 80% of the attempts. Further, the individual with tetraplegia succeeded in fully tongue controlling the assistive robot to reach for and touch a roll of tape in 100% of the attempts and to pick up the roll in 50% of the attempts. Furthermore, she controlled the robot to grasp a bottle of water and pour its contents into a cup; her first functional action in 19 years. To our knowledge, this is the first time that an individual with tetraplegia has been able to fully control an assistive robotic arm using a wireless intraoral tongue interface. The tongue interface used to control the robot is currently available for control of computers and of powered wheelchairs, and the robot employed in this study is also commercially available. Therefore, the presented results may translate into available solutions within reasonable time.

[Walking assist robot and its clinical application].

PubMed

Kakou, Hiroaki; Shitama, Hideo; Kimura, Yoshiko; Nakamoto, Yoko; Furuta, Nami; Honda, Kanae; Wada, Futoshi; Hachisuka, Kenji

2009-06-01

The walking assist robot was developed to improve gait disturbance in patients with severe disabilities. The robot had a trunk supporter, power generator and operating arms which held patient's lower extremities and simulated walking, a control unit, biofeedback system, and a treadmill. We applied the robot-aided gait training to three patients with severe gait disturbance induced by stroke, axonal Guillan-Barré syndrome or spinal cord injury, and the walking assist robot turned out to be effective in improving the gait disturbance.

Morbidity after conventional dissection of axillary lymph nodes in breast cancer patients

PubMed Central

2014-01-01

Background Conventional axillary lymph node dissection (ALND) has recently become less radical. The treatment morbidity effects of reduced ALND aggressiveness are unknown. This article investigates the prevalence of the main complications of ALND: lymphedema, range-of-motion restriction, and arm paresthesia and pain. Methods This cross-sectional study included 200 women with invasive breast cancer who underwent breast-conserving surgery (82.5%, n = 165) or mastectomy (17.5%, n = 35) with ALND from 2007 to 2011. Arm perimetry was used to assess lymphedema, defined as a difference >2 cm in the upper arm circumference between the nonsurgical and surgical arms. Range-of-motion restriction was assessed by evaluating the degree of arm abduction. Paresthesia was measured in the inner and proximal arm regions. Arm pain was assessed by directly questioning the patients and defined as either present or absent. Results The average (±SD) time between ALND and morbidity evaluation was 35 ± 18 months (range, 7-60 months). The average dissected lymph node number per patient was 14 ± 4 (range, 6-30 lymph nodes). Only 3.5% (n = 7) of the patients presented with lymphedema. Single-incision approaches to breast tumor and ALND (P = 0.04) and the presence of a postoperative seroma (P = 0.02) were associated with lymphedema in univariate analysis. Paresthesia was the most frequent side effect observed (53% of patients, n = 106). This complication was associated with increased age (P < 0.0001) and a larger dissected lymph node number (P = 0.01) in univariate and multivariate analysis. Additionally, 24% (n = 48) of patients had noticeable limited arm abduction. Among the patients, 27.5% (n = 55) experienced sporadic arm pain corresponding to the surgically treated armpit. In multivariate analysis, the pain risk was 1.9-fold higher in patients who underwent ALND corresponding to their dominant arm (95% CI, 1.0-3.7, P = 0.04). Conclusion Conventional ALND in breast cancer patients can result in unwanted complications. However, the current lymphedema prevalence is lower than that of the other analyzed side effects. PMID:24670000

The decisive role of the patient-side surgeon in robotic surgery.

PubMed

Sgarbura, Olivia; Vasilescu, Catalin

2010-12-01

Minimally invasive technology literature is mainly concerned about the feasibility of the robotic procedures and the performance of the console surgeon. However, few of these technologies could be applied without a well-trained team. Our goal was to demonstrate that robotic surgery depends more on the patient-side assistant surgeon's abilities than has been previously reported. In our department, 280 interventions in digestive, thoracic, and gynecological surgery were performed since the acquisition of the robotic equipment. There are three teams trained in robotic surgery with three console surgeons and four certified patient-side surgeons. Four more patient-side assistants were trained at our center. Trocar placement, docking and undocking of the robot, insertion of the laparoscopic instruments, and hemostatic maneuvers with various devices were quantified and compared. Assistants trained by using animal or cadaver surgery are more comfortable with the robotic instruments handling and with docking and undocking of the robot. Assistants who finalized their residency or attend their final year are more accurate with the insertion of the laparoscopic instrument to the targeted organ and more skillful with LigaSure or clip applier devices. Interventions that require vivid participation of the assistants have shorter assistant-depending time intervals at the end of the learning curve than at the beginning. Robotic surgery is a team effort and is greatly dependant on the performance of assistant surgeons. Interventions that have the benefit of a trained team are more rapid and secure.

Commentary on "Robot-assisted laparoscopic vs open radical cystectomy: Comparison of complications and perioperative oncological outcomes in 200 patients." Kader AK, Richards KA, Krane LS, Pettus JA, Smith JJ, Hemal AK, Division of Urology, UC San Diego Health System, San Diego, CA.: BJU Int 2013; 112(4):E290-4. doi:10.1111/bju.12167. [Epub 2013 Jul 1].

PubMed

See, William A

2014-11-01

To compare perioperative morbidity and oncological outcomes of robot-assisted laparoscopic radical cystectomy (RARC) to open RC (ORC) at a single institution. A retrospective analysis was performed on a consecutive series of patients undergoing RC (100 RARC and 100 ORC) at Wake Forest University with curative intent from 2006 until 2010. Complication data using the Clavien system were collected for 90 days postoperatively. Complications and other perioperative outcomes were compared between patient groups. Patients in both groups had comparable preoperative characteristics. The overall and major complication (Clavien ≥ 3) rates were lower for RARC patients at 35 vs 57% (P = 0.001) and 10 vs 22% (P = 0.019), respectively. There were no significant differences between groups for pathological outcomes, including stage, number of nodes harvested or positive margin rates. Our data suggest that patients undergoing RARC have perioperative oncological outcomes comparable with ORC, with fewer overall or major complications. Definitive claims about comparative outcomes with RARC require results from larger, randomised controlled trials. Copyright © 2014 Elsevier Inc. All rights reserved.

[A Case of Gastric Cancer Responding to Neoadjuvant Chemotherapy Leading to Histological Change to Grade 3].

PubMed

Osakabe, Hiroaki; Katayanagi, So; Makuuchi, Yousuke; Shigoka, Masatoshi; Sumi, Tetsuo; Tsuchida, Akihiko; Kawachi, Shigeyuki

2016-11-01

A 70-year-old man with cStage III A(cT3N2H0P0CYXM0)advanced gastric cancer in the lesser curvature with esophageal invasion and bulky lymph nodes was treated with S-1/CDDP. After 4 courses of chemotherapy, the tumor and lymph nodes were found to be reduced in a CT examination. Total gastrectomy with lymph node dissection(D2)was performed. Histopathological examination revealed no cancer cells in the stomach or lymph nodes, indicating Grade 3.

Robotic bariatric surgery: A general review of the current status.

PubMed

Jung, Minoa K; Hagen, Monika E; Buchs, Nicolas C; Buehler, Leo H; Morel, Philippe

2017-12-01

While conventional laparoscopy is the gold standard for almost all bariatric procedures, robotic assistance holds promise for facilitating complex surgeries and improving clinical outcomes. Since the report of the first robotic-assisted bariatric procedure in 1999, numerous publications, including those reporting comparative trials and meta-analyses across bariatric procedures with a focus on robotic assistance, can be found. This article reviews the current literature and portrays the perspectives of robotic bariatric surgery. While there are substantial reports on robotic bariatric surgery currently in publication, most studies suffer from low levels of evidence. As such, although robotics technology is without a doubt superior to conventional laparoscopy, the precise role of robotics in bariatric surgery is not yet clear. Copyright © 2017 John Wiley & Sons, Ltd.

Robotic instrumentation: Evolution and microsurgical applications

PubMed Central

Parekattil, Sijo J.; Moran, Michael E.

2010-01-01

This article presents a review of the history and evolution of robotic instrumentation and its applications in urology. A timeline for the evolution of robotic instrumentation is presented to better facilitate an understanding of our current-day applications. Some new directions including robotic microsurgical applications (robotic assisted denervation of the spermatic cord for chronic orchialgia and robotic assisted vasectomy reversal) are presented. There is a paucity of prospective comparative effectiveness studies for a number of robotic applications. However, right or wrong, human nature has always led to our infatuation with the concept of using tools to meet our needs. This chapter is a brief tribute to where we have come from and where we may be potentially heading in the field of robotic assisted urologic surgery. PMID:21116362

Robotic Fish to Aid Animal Behavior Studies and Informal Science Learning

NASA Astrophysics Data System (ADS)

Phamduy, Paul

The application of robotic fish in the fields of animal behavior and informal science learning are new and relatively untapped. In the context of animal behavior studies, robotic fish offers a consistent and customizable stimulus that could contribute to dissect the determinants of social behavior. In the realm of informal science learning, robotic fish are gaining momentum for the possibility of educating the general public simultaneously on fish physiology and underwater robotics. In this dissertation, the design and development of a number of robotic fish platforms and prototypes and their application in animal behavioral studies and informal science learning settings are presented. Robotic platforms for animal behavioral studies focused on the utilization replica or same scale prototypes. A novel robotic fish platform, featuring a three-dimensional swimming multi-linked robotic fish, was developed with three control modes varying in the level of robot autonomy offered. This platform was deployed at numerous science festivals and science centers, to obtain data on visitor engagement and experience.

Mixed reality for robotic treatment of a splenic artery aneurysm.

PubMed

Pietrabissa, Andrea; Morelli, Luca; Ferrari, Mauro; Peri, Andrea; Ferrari, Vincenzo; Moglia, Andrea; Pugliese, Luigi; Guarracino, Fabio; Mosca, Franco

2010-05-01

Techniques of mixed reality can successfully be used in preoperative planning of laparoscopic and robotic procedures and to guide surgical dissection and enhance its accuracy. A computer-generated three-dimensional (3D) model of the vascular anatomy of the spleen was obtained from the computed tomography (CT) dataset of a patient with a 3-cm splenic artery aneurysm. Using an environmental infrared localizer and a stereoscopic helmet, the surgeon can see the patient's anatomy in transparency (augmented or mixed reality). This arrangement simplifies correct positioning of trocars and locates surgical dissection directly on top of the aneurysm. In this way the surgeon limits unnecessary dissection, leaving intact the blood supply from the short gastric vessels and other collaterals. Based on preoperative planning, we were able to anticipate that the vascular exclusion of the aneurysm would result in partial splenic ischemia. To re-establish the flow to the spleen, end-to-end robotic anastomosis of the splenic artery with the Da Vinci surgical system was then performed. Finally, the aneurysm was fenestrated to exclude arterial refilling. The postoperative course was uneventful. A control CT scan 4 weeks after surgery showed a well-perfused and homogeneous splenic parenchyma. The final 3D model showed the fenestrated calcified aneurysm and patency of the re-anastomosed splenic artery. The described technique of robotic vascular exclusion of a splenic artery aneurysm, followed by re-anastomosis of the vessel, clearly demonstrates how this technology can reduce the invasiveness of the procedure, obviating an otherwise necessary splenectomy. Also, the use of intraoperative mixed-reality technology proved very useful in this case and is expected to play an increasing role in the operating room of the future.

PREOPERATIVE MRI IMPROVES PREDICTION OF EXTENSIVE OCCULT AXILLARY LYMPH NODE METASTASES IN BREAST CANCER PATIENTS WITH A POSITIVE SENTINEL LYMPH NODE BIOPSY

PubMed Central

Loiselle, Christopher; Eby, Peter R.; Kim, Janice N.; Calhoun, Kristine E.; Allison, Kimberly H.; Gadi, Vijayakrishna K.; Peacock, Sue; Storer, Barry; Mankoff, David A.; Partridge, Savannah C.; Lehman, Constance D.

2014-01-01

Rationale and Objectives To test the ability of quantitative measures from preoperative Dynamic Contrast Enhanced MRI (DCE-MRI) to predict, independently and/or with the Katz pathologic nomogram, which breast cancer patients with a positive sentinel lymph node biopsy will have ≥ 4 positive axillary lymph nodes upon completion axillary dissection. Methods and Materials A retrospective review was conducted to identify clinically node-negative invasive breast cancer patients who underwent preoperative DCE-MRI, followed by sentinel node biopsy with positive findings and complete axillary dissection (6/2005 – 1/2010). Clinical/pathologic factors, primary lesion size and quantitative DCE-MRI kinetics were collected from clinical records and prospective databases. DCE-MRI parameters with univariate significance (p < 0.05) to predict ≥ 4 positive axillary nodes were modeled with stepwise regression and compared to the Katz nomogram alone and to a combined MRI-Katz nomogram model. Results Ninety-eight patients with 99 positive sentinel biopsies met study criteria. Stepwise regression identified DCE-MRI total persistent enhancement and volume adjusted peak enhancement as significant predictors of ≥4 metastatic nodes. Receiver operating characteristic (ROC) curves demonstrated an area under the curve (AUC) of 0.78 for the Katz nomogram, 0.79 for the DCE-MRI multivariate model, and 0.87 for the combined MRI-Katz model. The combined model was significantly more predictive than the Katz nomogram alone (p = 0.003). Conclusion Integration of DCE-MRI primary lesion kinetics significantly improved the Katz pathologic nomogram accuracy to predict presence of metastases in ≥ 4 nodes. DCE-MRI may help identify sentinel node positive patients requiring further localregional therapy. PMID:24331270

Predictors of metastasis to lymph nodes posterior to the right recurrent laryngeal nerve in differentiated thyroid carcinoma: A prospective study.

PubMed

Liu, Ziwen; Sun, Mengqing; Xiao, Yiding; Yang, Jing; Zhang, Taiping; Zhao, Yupei

2017-07-01

To study the clinicopathological characteristics and the risk factors of lymph nodes posterior to the right recurrent laryngeal nerve (LN-prRLN) metastasis in differentiated thyroid carcinoma; and to identify the indication for LN-prRLN dissection. We treated 145 patients with differentiated thyroid carcinoma with appropriate surgical intervention. The specimens were examined by the pathologists. The right paratracheal lymph nodes were divided into two groups: anterior or posterior to right recurrent laryngeal nerve (VIa or VIp compartment, respectively). We recorded the clinical characteristics, histopathological features of the primary tumors, and lymph node metastasis of the patients. The results were statistically analyzed. There were 85 patients (58.6%) with central lymph node metastasis, of whom 61 (42.1%) had metastasis in VIa compartment; 16 patients (11.0%) had VIp subdistrict metastasis; and 25 patients had lateral lymph node metastasis. Multiplicity, larger tumor (≥1 cm), and coexistence of central lymph node metastasis, VIa compartment metastasis, and lateral lymph node metastasis were all significantly related with LN-prRLN metastasis, while sex, age, location of the tumor, and extrathyroid extension of the tumor showed no significant relation (p > 0.05). The incidence of LN-prRLN metastasis was lower than other central lymph nodes, as well as lymph nodes anterior to right recurrent laryngeal nerve. When there were multiple foci of tumors, or the tumor was larger than 1 cm, or central or lateral LN metastasis was indicated by preoperative ultrasound or confirmed by intraoperative frozen sections, it is strongly recommended that exploration and dissection of the LN-prRLN should only be performed by experienced surgeons. Copyright © 2016. Published by Elsevier Taiwan.

Number and Location of Positive Nodes, Postoperative Radiotherapy, and Survival After Esophagectomy With Three-Field Lymph Node Dissection for Thoracic Esophageal Squamous Cell Carcinoma

DOE Office of Scientific and Technical Information (OSTI.GOV)

Chen Junqiang; Pan Jianji, E-mail: panjianji@126.com; Zheng Xiongwei

2012-01-01

Purpose: To analyze influences of the number and location of positive lymph nodes and postoperative radiotherapy on survival for patients with thoracic esophageal squamous cell carcinoma (TE-SCC) treated with radical esophagectomy with three-field lymphadenectomy. Methods and Materials: A total of 945 patients underwent radical esophagectomy plus three-field lymph node dissection for node-positive TE-SCC at Fujian Provincial Tumor Hospital between January 1993 and March 2007. Five hundred ninety patients received surgery only (S group), and 355 patients received surgery, followed 3 to 4 weeks later by postoperative radiotherapy (S+R group) to a median total dose of 50 Gy in 25 fractions.more » We assessed potential associations among patient-, tumor-, and treatment-related factors and overall survival. Results: Five-year overall survival rates were 32.8% for the entire group, 29.6% for the S group, and 38.0% for the S+R group (p = 0.001 for S vs. S+R). Treatment with postoperative radiotherapy was particularly beneficial for patients with {>=}3 positive nodes and for those with metastasis in the upper (supraclavicular and upper mediastinal) region or both the upper and lower (mediastinal and abdominal) regions (p < 0.05). Postoperative radiotherapy was also associated with lower recurrence rates in the supraclavicular and upper and middle mediastinal regions (p < 0.05). Sex, primary tumor length, number of positive nodes, pathological T category, and postoperative radiotherapy were all independent predictors of survival. Conclusions: Postoperative radiotherapy was associated with better survival for patients with node-positive TE-SCC, particularly those with three or more positive nodes and positive nodes in the supraclavicular and superior mediastinal regions.« less

Lymph node metastasis after endoscopic submucosal dissection of a differentiated gastric cancer confined to the mucosa with an ulcer smaller than 30 mm.

PubMed

Fujii, Hiroyuki; Ishii, Eiji; Tochitani, Shinako; Nakaji, So; Hirata, Nobuto; Kusanagi, Hiroshi; Narita, Makoto

2015-01-01

In the expanded indications for endoscopic resection, Japanese guidelines for gastric cancer include differentiated cancers confined to the mucosa with an ulcer <30 mm. We describe a patient with lymph node metastasis after curative endoscopic submucosal dissection (ESD) for a tumor of this indication. The patient was a 70-year-old man with chronic hepatitis C. He underwent ESD for early gastric cancer in May 2010. Pathology revealed a moderately differentiated adenocarcinoma, 22 × 17 mm in size, that was confined to the mucosa with an ulcer. The horizontal and vertical margins were negative for the tumor. We diagnosed thiscase as curative resection of expanded indication and followed this patient with endoscopy, abdominal ultrasonography (AUS) or enhanced computed tomography (CT) approximately every 6 months. After 17 months, lymph node metastasis was detected with AUS and CT and diagnosed by endoscopic ultrasound-guided fine-needle aspiration biopsy in August 2011. Distal gastrectomy with D2 dissection was carried out in December 2011. Although it is low, the possibility of recurrence should be borne in mind after endoscopic treatment of early gastric cancer, despite its inclusion in the expanded indications for endoscopic resection. © 2014 The Authors. Digestive Endoscopy © 2014 Japan Gastroenterological Endoscopy Society.

Initial experience of robotic versus laparoscopic colectomy for transverse colon cancer: a matched case-control study.

PubMed

de'Angelis, Nicola; Alghamdi, Salah; Renda, Andrea; Azoulay, Daniel; Brunetti, Francesco

2015-10-09

Robotic surgery for transverse colon cancer has rarely been described. This study reports our initial experience in robotic resection for transverse colon cancer, by comparing robotic transverse colectomy (RC) to laparoscopic transverse colectomy (LC) in terms of safety, feasibility, short-term outcomes, and the surgeon's psychological stress and physical pain. The study population included the first 22 consecutive patients who underwent RC between March 2013 and December 2014 for histologically confirmed transverse colon adenocarcinoma. These patients were compared with 22 matched patients undergoing LC between December 2010 and February 2013. Patients were matched based on age, gender, body mass index (BMI), American Society of Anesthesiology (ASA) score, American Joint Committee on Cancer (AJCC) tumor stage, and tumor location (ratio 1:1). Mortality, morbidity, operative, and short-term oncologic outcomes were compared between groups. The operating surgeon's stress and pain were assessed before and after surgery on a 0-100-mm visual analog scale. The demographic and preoperative characteristics were comparable between RC and LC patients. No group difference was observed for intraoperative complications, blood loss, postoperative pain, time to flatus, time to regular diet, and hospital stay. RC was associated with longer operative time than LC (260 min vs. 225 min; p = 0.014), but the overall operative and robotic time in the RC group decreased over time reflecting the increasing experience in performing this procedure. No conversion to laparotomy was observed in the RC group, while two LC patients were converted due to uncontrolled bleeding and technically difficult middle colic pedicle dissection. Postoperative complications (Dindo-Clavien grade I or II) occurred in 11.3 % of patients with no group difference. Mortality was nil. All resections were R0, with >12 lymph nodes harvested in 90.9 % of RC and 95.5 % of LC patients. The surgeon's stress was not different between RC and LC, whereas the surgeon's hand and neck/shoulder pain were significantly lower after RC. RC for transverse colon cancer appears to be safe and feasible with short-term outcomes comparable to LC.

Movement Anticipation and EEG: Implications for BCI-Contingent Robot Therapy

PubMed Central

Norman, Sumner L.; Dennison, Mark; Wolbrecht, Eric; Cramer, Steven C.; Srinivasan, Ramesh; Reinkensmeyer, David J.

2017-01-01

Brain-computer interfacing is a technology that has the potential to improve patient engagement in robot-assisted rehabilitation therapy. For example, movement intention reduces mu (8-13 Hz) oscillation amplitude over the sensorimotor cortex, a phenomenon referred to as event-related desynchronization (ERD). In an ERD-contingent assistance paradigm, initial BCI-enhanced robotic therapy studies have used ERD to provide robotic assistance for movement. Here we investigated how ERD changed as a function of audio-visual stimuli, overt movement from the participant, and robotic assistance. Twelve unimpaired subjects played a computer game designed for rehabilitation therapy with their fingers using the FINGER robotic exoskeleton. In the game, the participant and robot matched movement timing to audio-visual stimuli in the form of notes approaching a target on the screen set to the consistent beat of popular music. The audio-visual stimulation of the game alone did not cause ERD, before or after training. In contrast, overt movement by the subject caused ERD, whether or not the robot assisted the finger movement. Notably, ERD was also present when the subjects remained passive and the robot moved their fingers to play the game. This ERD occurred in anticipation of the passive finger movement with similar onset timing as for the overt movement conditions. These results demonstrate that ERD can be contingent on expectation of robotic assistance; that is, the brain generates an anticipatory ERD in expectation of a robot-imposed but predictable movement. This is a caveat that should be considered in designing BCIs for enhancing patient effort in roboticallyassisted therapy. PMID:26891487

Evaluation of upper extremity robot-assistances in subacute and chronic stroke subjects.

PubMed

Ziherl, Jaka; Novak, Domen; Olenšek, Andrej; Mihelj, Matjaž; Munih, Marko

2010-10-18

Robotic systems are becoming increasingly common in upper extremity stroke rehabilitation. Recent studies have already shown that the use of rehabilitation robots can improve recovery. This paper evaluates the effect of different modes of robot-assistances in a complex virtual environment on the subjects' ability to complete the task as well as on various haptic parameters arising from the human-robot interaction. The MIMICS multimodal system that includes the haptic robot HapticMaster and a dynamic virtual environment is used. The goal of the task is to catch a ball that rolls down a sloped table and place it in a basket above the table. Our study examines the influence of catching assistance, pick-and-place movement assistance and grasping assistance on the catching efficiency, placing efficiency and on movement-dependent parameters: mean reaching forces, deviation error, mechanical work and correlation between the grasping force and the load force. The results with groups of subjects (23 subacute hemiparetic subjects, 10 chronic hemiparetic subjects and 23 control subjects) showed that the assistance raises the catching efficiency and pick-and-place efficiency. The pick-and-place movement assistance greatly limits the movements of the subject and results in decreased work toward the basket. The correlation between the load force and the grasping force exists in a certain phase of the movement. The results also showed that the stroke subjects without assistance and the control subjects performed similarly. The robot-assistances used in the study were found to be a possible way to raise the catching efficiency and efficiency of the pick-and-place movements in subacute and chronic subjects. The observed movement parameters showed that robot-assistances we used for our virtual task should be improved to maximize physical activity.

From Leonardo to da Vinci: the history of robot-assisted surgery in urology.

PubMed

Yates, David R; Vaessen, Christophe; Roupret, Morgan

2011-12-01

What's known on the subject? and What does the study add? Numerous urological procedures can now be performed with robotic assistance. Though not definitely proven to be superior to conventional laparoscopy or traditional open surgery in the setting of a randomised trial, in experienced centres robot-assisted surgery allows for excellent surgical outcomes and is a valuable tool to augment modern surgical practice. Our review highlights the depth of history that underpins the robotic surgical platform we utilise today, whilst also detailing the current place of robot-assisted surgery in urology in 2011. The evolution of robots in general and as platforms to augment surgical practice is an intriguing story that spans cultures, continents and centuries. A timeline from Yan Shi (1023-957 bc), Archytas of Tarentum (400 bc), Aristotle (322 bc), Heron of Alexandria (10-70 ad), Leonardo da Vinci (1495), the Industrial Revolution (1790), 'telepresence' (1950) and to the da Vinci(®) Surgical System (1999), shows the incredible depth of history and development that underpins the modern surgical robot we use to treat our patients. Robot-assisted surgery is now well-established in Urology and although not currently regarded as a 'gold standard' approach for any urological procedure, it is being increasingly used for index operations of the prostate, kidney and bladder. We perceive that robotic evolution will continue infinitely, securing the place of robots in the history of Urological surgery. Herein, we detail the history of robots in general, in surgery and in Urology, highlighting the current place of robot-assisted surgery in radical prostatectomy, partial nephrectomy, pyeloplasty and radical cystectomy. © 2011 THE AUTHORS. BJU INTERNATIONAL © 2011 BJU INTERNATIONAL.

Acceptance of an assistive robot in older adults: a mixed-method study of human-robot interaction over a 1-month period in the Living Lab setting.

PubMed

Wu, Ya-Huei; Wrobel, Jérémy; Cornuet, Mélanie; Kerhervé, Hélène; Damnée, Souad; Rigaud, Anne-Sophie

2014-01-01

There is growing interest in investigating acceptance of robots, which are increasingly being proposed as one form of assistive technology to support older adults, maintain their independence, and enhance their well-being. In the present study, we aimed to observe robot-acceptance in older adults, particularly subsequent to a 1-month direct experience with a robot. Six older adults with mild cognitive impairment (MCI) and five cognitively intact healthy (CIH) older adults were recruited. Participants interacted with an assistive robot in the Living Lab once a week for 4 weeks. After being shown how to use the robot, participants performed tasks to simulate robot use in everyday life. Mixed methods, comprising a robot-acceptance questionnaire, semistructured interviews, usability-performance measures, and a focus group, were used. Both CIH and MCI subjects were able to learn how to use the robot. However, MCI subjects needed more time to perform tasks after a 1-week period of not using the robot. Both groups rated similarly on the robot-acceptance questionnaire. They showed low intention to use the robot, as well as negative attitudes toward and negative images of this device. They did not perceive it as useful in their daily life. However, they found it easy to use, amusing, and not threatening. In addition, social influence was perceived as powerful on robot adoption. Direct experience with the robot did not change the way the participants rated robots in their acceptance questionnaire. We identified several barriers to robot-acceptance, including older adults' uneasiness with technology, feeling of stigmatization, and ethical/societal issues associated with robot use. It is important to destigmatize images of assistive robots to facilitate their acceptance. Universal design aiming to increase the market for and production of products that are usable by everyone (to the greatest extent possible) might help to destigmatize assistive devices.

Acceptance of an assistive robot in older adults: a mixed-method study of human–robot interaction over a 1-month period in the Living Lab setting

PubMed Central

Wu, Ya-Huei; Wrobel, Jérémy; Cornuet, Mélanie; Kerhervé, Hélène; Damnée, Souad; Rigaud, Anne-Sophie

2014-01-01

Background There is growing interest in investigating acceptance of robots, which are increasingly being proposed as one form of assistive technology to support older adults, maintain their independence, and enhance their well-being. In the present study, we aimed to observe robot-acceptance in older adults, particularly subsequent to a 1-month direct experience with a robot. Subjects and methods Six older adults with mild cognitive impairment (MCI) and five cognitively intact healthy (CIH) older adults were recruited. Participants interacted with an assistive robot in the Living Lab once a week for 4 weeks. After being shown how to use the robot, participants performed tasks to simulate robot use in everyday life. Mixed methods, comprising a robot-acceptance questionnaire, semistructured interviews, usability-performance measures, and a focus group, were used. Results Both CIH and MCI subjects were able to learn how to use the robot. However, MCI subjects needed more time to perform tasks after a 1-week period of not using the robot. Both groups rated similarly on the robot-acceptance questionnaire. They showed low intention to use the robot, as well as negative attitudes toward and negative images of this device. They did not perceive it as useful in their daily life. However, they found it easy to use, amusing, and not threatening. In addition, social influence was perceived as powerful on robot adoption. Direct experience with the robot did not change the way the participants rated robots in their acceptance questionnaire. We identified several barriers to robot-acceptance, including older adults’ uneasiness with technology, feeling of stigmatization, and ethical/societal issues associated with robot use. Conclusion It is important to destigmatize images of assistive robots to facilitate their acceptance. Universal design aiming to increase the market for and production of products that are usable by everyone (to the greatest extent possible) might help to destigmatize assistive devices. PMID:24855349

Which biopsy method is more suitable between a basin dissection and pick-up biopsy for sentinel nodes in laparoscopic sentinel-node navigation surgery (LSNNS) for gastric cancer?

PubMed

Lee, Young-Joon; Ha, Woo-Song; Park, Soon-Tae; Choi, Sang-Kyung; Hong, Soon-Chan; Park, Jung-Woo

2008-06-01

Sentinel-node navigation surgery (SNNS) for breast cancer and melanoma has been accepted as a reasonable oncologic surgery worldwide. On the other hand, in gastric cancers that do metastasize well to the lymph node, the use of SNNS has been approached with care and performed in only limited cases. Some obstacles still have to be overcome, such as the shortcomings of SN tracers and the technical limitations of laparoscopic SN detection. The aims of this study were to determine whether laparoscopic SNNS is possible, and which biopsy method is more suitable for SN tracers, in gastric cancer, preoperatively diagnosed as < or =T2 and with < or =4-cm-sized lesions. Between January 2005 and October 2006, 92 consecutive patients that underwent LSNNS, using a combined indocyanine green and (99m)Tc-labeled tin colloid technique, were prospectively studied. SNs were laparoscopically removed by using two biopsy methods: a basin dissection and pick-up method, with the results of these two SN biopsy methods then compared with the final diagnosis obtained from a permanent section. With the pick-up method, SNs were identified in 23 of 42 patients (54.8%); however, with basin dissection, the detection rate was 96% (48 of 50 patients). The average number of SNs detected by the two methods were 2.1 (range, 0-4) and 3.5 (range, 1-7), respectively. The sensitivities of the two methods were 66% (4/6) and 85.7% (12/14), with specificities of 100% (17/17) and 100% (34/34), respectively. In gastric cancer, it was possible to perform LSNNS. At this moment, we believe the laparoscopic basin dissection technique with a dual-tracer injection, followed by SN detection on the back table, will be a reasonable procedure for gastric cancer, owing to the shortcomings related to the dye and radioisotope, the so-called "stained lymphatic duct only" and "shine-through phenomenon."

Utility of PET-CT in detecting nodal metastasis in cN0 early stage oral cavity squamous cell carcinoma.

PubMed

Zhang, Han; Seikaly, Hadi; Biron, Vincent L; Jeffery, Caroline C

2018-05-01

Management of the clinically node-negative neck (cN0) in patients with early stage oral cavity squamous cell carcinoma (OCSCC) is challenging. Accurate imaging alternatives to elective neck dissections would help reduce surgical morbidity. While pooled studies suggest that imaging modalities have similar accuracy in predicting occult nodal disease, no study has examined the utility of PET-CT in this specific population of low-volume, clinically T1 and T2 OCSCC patients. A retrospective review of patients in the Alberta Cancer Registry who were diagnosed with cT1 or T2N0M0 OCSCC who underwent elective unilateral or bilateral neck dissections was performed. Pre-operative PET-CT and CT necks were reviewed for number of radiographically suspicious lymph nodes. Surgical pathology reports were reviewed to obtain the total number of nodes sampled and number of malignant nodes. Between 2009 and 2013, 148 patients were diagnosed with cT1 or T2N0M0 OCSCC. Of these, 96 patients underwent elective neck dissections. All patients underwent preoperative CT of the neck with 32 patients having undergone additional preoperative PET-CT. Based on finally surgical pathology, the overall rate of occult metastasis was 13.5% (13/96). The overall sensitivity and specificity of PET-CT in this cohort was 21.4% and 98.4%, respectively with a negative predictive value of 99.1%. Although sensitivity improved in patients with tumors ≥2 cm and depth ≥4 mm, specificity remained unchanged. In patients with cT1 and T2N0 OCSCC, PET-CT has high negative predictive value. These patients can be considered for treatment with single modality surgical resection and elective neck dissection. Copyright © 2018 Elsevier Ltd. All rights reserved.

One-Hour PTH after Thyroidectomy Predicts Symptomatic Hypocalcemia

PubMed Central

Nocon, Cheryl; Nagar, Sapna; Kaplan, Edwin L.; Angelos, Peter; Grogan, Raymon H.

2015-01-01

Background A major morbidity following total thyroidectomy is hypocalcemia. While many clinical factors and laboratory studies have been correlated with both biochemical and symptomatic hypocalcemia, the ideal use and timing of these tests the remains unclear. We hypothesize one-hour (PACU) PTH will identify patients at risk for symptomatic hypocalcemia. Methods This prospective study evaluated 196 patients undergoing total thyroidectomy. Serum calcium and PTH levels were measured one hour after surgery and on postoperative day 1 (POD1). Performance of a central compartment lymph node dissection, parathyroid autotransplantation, indication for procedure, pathology, and presence of parathyroid tissue in the pathology specimen were recorded. Results Of 196 patients, 9 (4.6%) developed symptomatic hypocalcemia. 34 (17.3%) had a 1-hour PACU PTH ≤ 10 pg/dL while 31 (15.8%) had a POD1 PTH of ≤ 10. Five (56%) of the nine symptomatic patients underwent central compartment lymph node dissection, 4 (44%) had parathyroid autotransplantation and 4 (44%) had a PACU PTH ≤10. PACU and POD1 PTH levels were correlated (R2=0.682). Multivariate regression identified central compartment dissection, autotransplantation, and PACU or POD1 PTH correlated with symptomatic hypocalcemia. PACU PTH, POD1 PTH, PACU Ca, malignant final pathology, and Age ≤ 45 years correlated with biochemical hypocalcemia. Conclusion 1-hour postoperative PACU PTH is equivalent to POD1 PTH in predicting the development of symptomatic hypocalcemia. Biochemical hypocalcemia was not predictive of symptoms in the immediate post-operative period. Lymph node dissection and parathyroid autotransplantation correlated with symptomatic hypocalcemia and improve the sensitivity of biochemical screening alone. PMID:27020834

One-hour PTH after thyroidectomy predicts symptomatic hypocalcemia.

PubMed

White, Michael G; James, Benjamin C; Nocon, Cheryl; Nagar, Sapna; Kaplan, Edwin L; Angelos, Peter; Grogan, Raymon H

2016-04-01

A major morbidity after total thyroidectomy is hypocalcemia. Although many clinical factors and laboratory studies have been correlated with both biochemical and symptomatic hypocalcemia, the ideal use and timing of these tests remain unclear. We hypothesize 1-h (PACU) parathyroid hormone (PTH) will identify patients at risk for symptomatic hypocalcemia. This prospective study evaluated 196 patients undergoing total thyroidectomy. Serum calcium and PTH levels were measured 1 h after surgery and on postoperative day 1 (POD1). Performance of a central compartment lymph node dissection, parathyroid autotransplantation, indication for procedure, pathology, and presence of parathyroid tissue in the pathology specimen were recorded. Of 196 patients, nine (4.6%) developed symptomatic hypocalcemia. Thirty four (17.3%) had a 1-h PACU PTH ≤10 pg/dL, whereas 31 (15.8%) had a POD1 PTH of ≤10. Five (56%) of the nine symptomatic patients underwent central compartment lymph node dissection, four (44%) had parathyroid autotransplantation, and four (44%) had a PACU PTH ≤10. PACU and POD1 PTH levels were correlated (R(2) = 0.682). Multivariate regression identified central compartment dissection, autotransplantation, and PACU or POD1 PTH correlated with symptomatic hypocalcemia. PACU PTH, POD1 PTH, PACU Ca, malignant final pathology, and age ≤45 y correlated with biochemical hypocalcemia. A 1-h postoperative PACU PTH is equivalent to POD1 PTH in predicting the development of symptomatic hypocalcemia. Biochemical hypocalcemia was not predictive of symptoms in the immediate postoperative period. Lymph node dissection and parathyroid autotransplantation correlated with symptomatic hypocalcemia and improve the sensitivity of biochemical screening alone. Copyright © 2016 Elsevier Inc. All rights reserved.

Local anesthetic delivery via surgical drain provides improved pain control versus direct skin infiltration following axillary node dissection for breast cancer.

PubMed

Khpal, Muska; Miller, James R C; Petrovic, Zika; Hassanally, Delilah

2018-03-01

Axillary node dissection has a central role in the surgical management of breast cancer; however, it is associated with a significant risk of lymphoedema and chronic pain. Peri-operative administration of local anesthesia reduces acute and persistent post-surgical pain, but there is currently no consensus on the optimal method of local anesthetic delivery. Patients undergoing axillary dissection for breast cancer were randomly assigned to receive a one-off dose of levobupivacaine 0.5% (up to 2 mg/kg) following surgery, either via the surgical drain or by direct skin infiltration. Post-operative pain control at rest and on shoulder abduction was assessed using a numerical rating scale. Total analgesia consumption 48 h after surgery was also recorded. Pain scores were significantly lower when local anesthesia was administered via surgical drain at both 3 and 12 h after surgery; this trend extended to 24 h post-operatively. However, pain scores on shoulder abduction did not differ at the 12 or 24 h time points. No differences were found in the total analgesia consumption or length of hospital stay between treatment groups. This study demonstrates that local anesthetic delivery via a surgical drain provides improved pain control compared to direct skin infiltration following axillary node dissection. This is likely to be important for the management of acute pain in the immediate post-operative period; however, further studies may be required to validate this in specific patient subgroups, e.g., breast-conserving surgery versus mastectomy.

Robotic Surgical System for Radical Prostatectomy: A Health Technology Assessment

PubMed Central

Wang, Myra; Xie, Xuanqian; Wells, David; Higgins, Caroline

2017-01-01

Background Prostate cancer is the second most common type of cancer in Canadian men. Radical prostatectomy is one of the treatment options available, and involves removing the prostate gland and surrounding tissues. In recent years, surgeons have begun to use robot-assisted radical prostatectomy more frequently. We aimed to determine the clinical benefits and harms of the robotic surgical system for radical prostatectomy (robot-assisted radical prostatectomy) compared with the open and laparoscopic surgical methods. We also assessed the cost-effectiveness of robot-assisted versus open radical prostatectomy in patients with clinically localized prostate cancer in Ontario. Methods We performed a literature search and included prospective comparative studies that examined robot-assisted versus open or laparoscopic radical prostatectomy for prostate cancer. The outcomes of interest were perioperative, functional, and oncological. The quality of the body of evidence was examined according to the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) Working Group criteria. We also conducted a cost–utility analysis with a 1-year time horizon. The potential long-term benefits of robot-assisted radical prostatectomy for functional and oncological outcomes were also evaluated in a 10-year Markov model in scenario analyses. In addition, we conducted a budget impact analysis to estimate the additional costs to the provincial budget if the adoption of robot-assisted radical prostatectomy were to increase in the next 5 years. A needs assessment determined that the published literature on patient perspectives was relatively well developed, and that direct patient engagement would add relatively little new information. Results Compared with the open approach, we found robot-assisted radical prostatectomy reduced length of stay and blood loss (moderate quality evidence) but had no difference or inconclusive results for functional and oncological outcomes (low to moderate quality evidence). Compared with laparoscopic radical prostatectomy, robot-assisted radical prostatectomy had no difference in perioperative, functional, and oncological outcomes (low to moderate quality evidence). Compared with open radical prostatectomy, our best estimates suggested that robot-assisted prostatectomy was associated with higher costs ($6,234) and a small gain in quality-adjusted life-years (QALYs) (0.0012). The best estimate of the incremental cost-effectiveness ratio (ICER) was $5.2 million per QALY gained. However, if robot-assisted radical prostatectomy were assumed to have substantially better long-term functional and oncological outcomes, the ICER might be as low as $83,921 per QALY gained. We estimated the annual budget impact to be $0.8 million to $3.4 million over the next 5 years. Conclusions There is no high-quality evidence that robot-assisted radical prostatectomy improves functional and oncological outcomes compared with open and laparoscopic approaches. However, compared with open radical prostatectomy, the costs of using the robotic system are relatively large while the health benefits are relatively small. PMID:28744334

Does haptic robot-assisted total hip arthroplasty better restore native acetabular and femoral anatomy?

PubMed

Tsai, Tsung-Yuan; Dimitriou, Dimitris; Li, Jing-Sheng; Kwon, Young-Min

2016-06-01

The objective was to evaluate whether total hip arthroplasty (THA) using haptic robot assistance restores hip geometry better than the free-hand technique. Twelve robot-assisted and 14 free-hand unilateral THA patients underwent CT scan for three-dimensional (3D) hip models. The anteversion, inclination and hip joint centre locations of the native and implanted hips in each patient were quantified and compared. Significant increase of combined anteversion by 19.1 ± 11.7° and 23.5 ± 23.6° and decrease of cup inclination by 16.5 ± 6.0° and 10.2 ± 6.8° were observed in the robot-assisted and the free-hand THAs, respectively. Less variation in the difference of the component orientations (max 11.1 vs 18.3°) and the femoral head centre (max 4.5 vs 6.3 mm) were found in the robot-assisted group. This study demonstrated that neither robot-assisted nor free-hand THAs had fully restored native hip geometry. However, the higher precision of the robot-assisted THA suggested that it has potential utility in restoring the native hip geometry. Copyright © 2015 John Wiley & Sons, Ltd. Copyright © 2015 John Wiley & Sons, Ltd.

Human-robot cooperative movement training: Learning a novel sensory motor transformation during walking with robotic assistance-as-needed

PubMed Central

Emken, Jeremy L; Benitez, Raul; Reinkensmeyer, David J

2007-01-01

Background A prevailing paradigm of physical rehabilitation following neurologic injury is to "assist-as-needed" in completing desired movements. Several research groups are attempting to automate this principle with robotic movement training devices and patient cooperative algorithms that encourage voluntary participation. These attempts are currently not based on computational models of motor learning. Methods Here we assume that motor recovery from a neurologic injury can be modelled as a process of learning a novel sensory motor transformation, which allows us to study a simplified experimental protocol amenable to mathematical description. Specifically, we use a robotic force field paradigm to impose a virtual impairment on the left leg of unimpaired subjects walking on a treadmill. We then derive an "assist-as-needed" robotic training algorithm to help subjects overcome the virtual impairment and walk normally. The problem is posed as an optimization of performance error and robotic assistance. The optimal robotic movement trainer becomes an error-based controller with a forgetting factor that bounds kinematic errors while systematically reducing its assistance when those errors are small. As humans have a natural range of movement variability, we introduce an error weighting function that causes the robotic trainer to disregard this variability. Results We experimentally validated the controller with ten unimpaired subjects by demonstrating how it helped the subjects learn the novel sensory motor transformation necessary to counteract the virtual impairment, while also preventing them from experiencing large kinematic errors. The addition of the error weighting function allowed the robot assistance to fade to zero even though the subjects' movements were variable. We also show that in order to assist-as-needed, the robot must relax its assistance at a rate faster than that of the learning human. Conclusion The assist-as-needed algorithm proposed here can limit error during the learning of a dynamic motor task. The algorithm encourages learning by decreasing its assistance as a function of the ongoing progression of movement error. This type of algorithm is well suited for helping people learn dynamic tasks for which large kinematic errors are dangerous or discouraging, and thus may prove useful for robot-assisted movement training of walking or reaching following neurologic injury. PMID:17391527

Retzius space reconstruction following transperitoneal laparoscopic robot-assisted radical prostatectomy: does it have any added value?

PubMed

Abu-Ghanem, Yasmin; Dotan, Zohar; Ramon, Jacob; Zilberman, Dorit E

2017-11-27

Retzius space sparing (RSS) during laparoscopic robot-assisted radical prostatectomy (RALP) has been offered as an approach that reduces perioperative complications and enables faster gaining of full urinary continence due to bladder anatomy preservation. Retro and transperitoneal techniques have been proposed, whereby RSS has been implemented. We sought to explore whether Retzius space reconstruction (RSR) following transperitoneal RALP will be an advantageous step as well. A prospective registry database of 102 consecutive transperitoneal RALP cases performed by a single surgeon was reviewed. The Retzius space had been opened by dissecting the bladder away from the anterior abdominal wall to the level of both internal rings. In the last 51 cases (RSR group), the peritoneal layer had been sutured back, thus repositioning the bladder back to the anterior abdominal wall and reconstructing the Retzius space. Perioperative factors were analyzed and compared between the two groups. Demographic and perioperative data did not differ between the two groups. RSR group demonstrated shorter length of stay (LOS) compared with the control group (p = 0.01), as well as faster urinary continence recovery (i.e., 0 pads) (p = 0.01). Moreover, lower numbers of Clavien-Dindo class 3 complications and 12 mm port-site hernias (p = 0.03) were seen in the RSR group compared with the control group. RSR following transperitoneal RALP is a simple and efficient step that potentially reduces early and late post-operative complications, shortens LOS and accelerates full urinary continence.

Acceptance and Attitudes Toward a Human-like Socially Assistive Robot by Older Adults.

PubMed

Louie, Wing-Yue Geoffrey; McColl, Derek; Nejat, Goldie

2014-01-01

Recent studies have shown that cognitive and social interventions are crucial to the overall health of older adults including their psychological, cognitive, and physical well-being. However, due to the rapidly growing elderly population of the world, the resources and people to provide these interventions is lacking. Our work focuses on the use of social robotic technologies to provide person-centered cognitive interventions. In this article, we investigate the acceptance and attitudes of older adults toward the human-like expressive socially assistive robot Brian 2.1 in order to determine if the robot's human-like assistive and social characteristics would promote the use of the robot as a cognitive and social interaction tool to aid with activities of daily living. The results of a robot acceptance questionnaire administered during a robot demonstration session with a group of 46 elderly adults showed that the majority of the individuals had positive attitudes toward the socially assistive robot and its intended applications.

Cost-analysis of robotic-assisted laparoscopic hysterectomy versus total abdominal hysterectomy for women with endometrial cancer and atypical complex hyperplasia.

PubMed

Herling, Suzanne F; Palle, Connie; Møller, Ann M; Thomsen, Thordis; Sørensen, Jan

2016-03-01

The aim of this study was to analyse the hospital cost of treatment with robotic-assisted laparoscopic hysterectomy and total abdominal hysterectomy for women with endometrial cancer or atypical complex hyperplasia and to identify differences in resource use and cost. This cost analysis was based on two cohorts: women treated with robotic-assisted laparoscopic hysterectomy (n = 202) or with total abdominal hysterectomy (n = 158) at Copenhagen University Hospital, Herlev, Denmark. We conducted an activity-based cost analysis including consumables and healthcare professionals' salaries. As cost-drivers we included severe complications, duration of surgery, anesthesia and stay at the post-anesthetic care unit, as well as number of hospital bed-days. Ordinary least-squares regression was used to explore the cost variation. The primary outcome was cost difference in Danish kroner between total abdominal hysterectomy and robotic-assisted laparoscopic hysterectomy. The average cost of consumables was 12,642 Danish kroner more expensive per patient for robotic-assisted laparoscopic hysterectomy than for total abdominal hysterectomy (2014 price level: 1€ = 7.50 Danish kroner). When including all cost-drivers, the analysis showed that the robotic-assisted laparoscopic hysterectomy procedure was 9386 Danish kroner (17%) cheaper than the total abdominal hysterectomy (p = 0.003). When the robot investment was included, the cost difference reduced to 4053 Danish kroner (robotic-assisted laparoscopic hysterectomy was 7% cheaper than total abdominal hysterectomy) (p = 0.20). Increasing age and Type 2 diabetes appeared to influence the overall costs. For women with endometrial cancer or atypical complex hyperplasia, robotic-assisted laparoscopic hysterectomy was cheaper than total abdominal hysterectomy, mostly due to fewer complications and shorter length of hospital stay. © 2015 Nordic Federation of Societies of Obstetrics and Gynecology.

Artificial urinary sphincter implantation in women with stress urinary incontinence: preliminary comparison of robot-assisted and open approaches.

PubMed

Peyronnet, Benoit; Vincendeau, Sébastien; Tondut, Lauranne; Bensalah, Karim; Damphousse, Mireille; Manunta, Andréa

2016-03-01

We aimed to compare outcomes of open and robot-assisted artificial urinary sphincter (AUS) implantation in female patients. The charts of all female patients who underwent an AUS implantation between 2008 and 2014 in a single center were retrospectively reviewed. From 2008 to 2012, AUS were implanted using an open approach and from 2013 to 2014 using a robot-assisted approach. Perioperative and functional parameters were compared between groups. The primary endpoint was continence status. Twenty-four women were assessed: 16 in the open group and eight in the robot-assisted group. Three patients had neurogenic stress urinary incontinence. Most patients had undergone previous procedures for urinary incontinence (15 in the open group and seven in the robotic group). Mean operative time was similar in both groups (214 vs. 211 min; p = 0.90). Postoperative complicationsrate was lower in the robot-assisted group (25 vs. 75 %; p = 0.02). There was a trend toward a lower intraoperative complication rate (37.5 vs. 62.5 %; p = 0.25), decreased blood loss (17 ml vs. 275 ml; p = 0.22), and shorter length of stay (3.5 vs. 9.3 days; p = 0.09) in the robot-assisted group. Continence rates were comparable in both groups (75 vs. 68.8 %; p = 0.75). Three AUS explantations were needed in the open group (18.8 %) compared with one in the robot-assisted group (12.5 %; p = 0.70). In female patients, the robot-assisted approach compared with open AUS implantation could decrease intraoperative and postoperative complication rates, length of hospital stay, and blood loss.

Robot assistance of motor learning: A neuro-cognitive perspective.

PubMed

Heuer, Herbert; Lüttgen, Jenna

2015-09-01

The last several years have seen a number of approaches to robot assistance of motor learning. Experimental studies have produced a range of findings from beneficial effects through null-effects to detrimental effects of robot assistance. In this review we seek an answer to the question under which conditions which outcomes should be expected. For this purpose we derive tentative predictions based on a classification of learning tasks in terms of the products of learning, the mechanisms involved, and the modulation of these mechanisms by robot assistance. Consistent with these predictions, the learning of dynamic features of trajectories is facilitated and the learning of kinematic and dynamic transformations is impeded by robotic guidance, whereas the learning of dynamic transformations can profit from robot assistance with error-amplifying forces. Deviating from the predictions, learning of spatial features of trajectories is impeded by haptic guidance, but can be facilitated by divergent force fields. The deviations point to the existence of additional effects of robot assistance beyond the modulation of learning mechanisms, e.g., the induction of a passive role of the motor system during practice with haptic guidance. Copyright © 2015 Elsevier Ltd. All rights reserved.

Impact of splenic hilar lymph node metastasis on prognosis in patients with advanced gastric cancer

PubMed Central

Son, Taeil; Kwon, In Gyu; Lee, Joong Ho; Choi, Youn Young; Kim, Hyoung-Il; Cheong, Jae-Ho; Noh, Sung Hoon; Hyung, Woo Jin

2017-01-01

Background: Impact of splenic hilar LN dissection during total gastrectomy for proximal advanced gastric cancer is controversial. The objective of this study was to assess the impact on prognosis of splenic hilar lymph node(LN) metastasis compared to that of metastasis to other regional LN groups. Study Design Patients who underwent total gastrectomy with D2 LN dissection from 2000 to 2010 were reviewed retrospectively. The clinicopathologic characteristics and long-term results of patients with splenic hilar LN metastasis were compared to those of patients with only metastasis to other extraperigastric LNs (stations #8a, #9, #11, or #12a). To investigate the survival benefit of performing splenic hilar LN dissection, the estimated therapeutic index for the procedure was calculated by multiplying the incidence of metastases in the hilar region by the survival rates for individuals with nodal involvement in that region. Results Of 602 patients, 87(14.5%) had hilar LN metastasis. The 5-year overall and relapse-free survival rates for patients with hilar LN metastasis were 24.1% and 12.1%, respectively. These rates were similar to those for patients with metastasis to other extraperigastric LNs (P > 0.05), with similar recurrence patterns. Overall survival in the hilar LN metastasis group was better than that for patients with distant metastasis(P < 0.05). The estimated therapeutic index of splenic hilar LN dissection was 3.5, which was similar to index values for LN dissection at other extraperigastric LNs. Conclusions Dissection of splenic hilar LNs during total gastrectomy for advanced gastric cancer allows for a prognosis similar to that achieved with dissection of extraperigastric LNs. PMID:29137444

Parametric binary dissection

NASA Technical Reports Server (NTRS)

Bokhari, Shahid H.; Crockett, Thomas W.; Nicol, David M.

1993-01-01

Binary dissection is widely used to partition non-uniform domains over parallel computers. This algorithm does not consider the perimeter, surface area, or aspect ratio of the regions being generated and can yield decompositions that have poor communication to computation ratio. Parametric Binary Dissection (PBD) is a new algorithm in which each cut is chosen to minimize load + lambda x(shape). In a 2 (or 3) dimensional problem, load is the amount of computation to be performed in a subregion and shape could refer to the perimeter (respectively surface) of that subregion. Shape is a measure of communication overhead and the parameter permits us to trade off load imbalance against communication overhead. When A is zero, the algorithm reduces to plain binary dissection. This algorithm can be used to partition graphs embedded in 2 or 3-d. Load is the number of nodes in a subregion, shape the number of edges that leave that subregion, and lambda the ratio of time to communicate over an edge to the time to compute at a node. An algorithm is presented that finds the depth d parametric dissection of an embedded graph with n vertices and e edges in O(max(n log n, de)) time, which is an improvement over the O(dn log n) time of plain binary dissection. Parallel versions of this algorithm are also presented; the best of these requires O((n/p) log(sup 3)p) time on a p processor hypercube, assuming graphs of bounded degree. How PBD is applied to 3-d unstructured meshes and yields partitions that are better than those obtained by plain dissection is described. Its application to the color image quantization problem is also discussed, in which samples in a high-resolution color space are mapped onto a lower resolution space in a way that minimizes the color error.

Application of robotics in gastrointestinal endoscopy: A review

PubMed Central

Yeung, Baldwin Po Man; Chiu, Philip Wai Yan

2016-01-01

Multiple robotic flexible endoscope platforms have been developed based on cross specialty collaboration between engineers and medical doctors. However, significant number of these platforms have been developed for the natural orifice transluminal endoscopic surgery paradigm. Increasing amount of evidence suggest the focus of development should be placed on advanced endolumenal procedures such as endoscopic submucosal dissection instead. A thorough literature analysis was performed to assess the current status of robotic flexible endoscopic platforms designed for advanced endolumenal procedures. Current efforts are mainly focused on robotic locomotion and robotic instrument control. In the future, advances in actuation and servoing technology, optical analysis, augmented reality and wireless power transmission technology will no doubt further advance the field of robotic endoscopy. Globally, health systems have become increasingly budget conscious; widespread acceptance of robotic endoscopy will depend on careful design to ensure its delivery of a cost effective service. PMID:26855540

Development of an LSI for Tactile Sensor Systems on the Whole-Body of Robots

NASA Astrophysics Data System (ADS)

Muroyama, Masanori; Makihata, Mitsutoshi; Nakano, Yoshihiro; Matsuzaki, Sakae; Yamada, Hitoshi; Yamaguchi, Ui; Nakayama, Takahiro; Nonomura, Yutaka; Fujiyoshi, Motohiro; Tanaka, Shuji; Esashi, Masayoshi

We have developed a network type tactile sensor system, which realizes high-density tactile sensors on the whole-body of nursing and communication robots. The system consists of three kinds of nodes: host, relay and sensor nodes. Roles of the sensor node are to sense forces and, to encode the sensing data and to transmit the encoded data on serial channels by interruption handling. Relay nodes and host deal with a number of the encoded sensing data from the sensor nodes. A sensor node consists of a capacitive MEMS force sensor and a signal processing/transmission LSI. In this paper, details of an LSI for the sensor node are described. We designed experimental sensor node LSI chips by a commercial 0.18µm standard CMOS process. The 0.18µm LSIs were supplied in wafer level for MEMS post-process. The LSI chip area is 2.4mm × 2.4mm, which includes logic, CF converter and memory circuits. The maximum clock frequency of the chip with a large capacitive load is 10MHz. Measured power consumption at 10MHz clock is 2.23mW. Experimental results indicate that size, response time, sensor sensitivity and power consumption are all enough for practical tactile sensor systems.

Robotic learning from demonstration of therapist's time-varying assistance to a patient in trajectory-following tasks.

PubMed

Najafi, Mohammad; Adams, Kim; Tavakoli, Mahdi

2017-07-01

The number of people with physical disabilities and impaired motion control is increasing. Consequently, there is a growing demand for intelligent assistive robotic systems to cooperate with people with disability and help them carry out different tasks. To this end, our group has pioneered the use of robot learning from demonstration (RLfD) techniques, which eliminate the need for task-specific robot programming, in robotic rehabilitation and assistive technologies settings. First, in the demonstration phase, the therapist (or in general, a helper) provides an intervention (typically assistance) and cooperatively performs a task with a patient several times. The demonstrated motion is modelled by a statistical RLfD algorithm, which will later be used in the robot controllers to reproduce a similar intervention robotically. In this paper, by proposing a Tangential-Normal Varying-Impedance Controller (TNVIC), the robotic manipulator not only follows the therapist's demonstrated motion, but also mimics his/her interaction impedance during the therapeutic/assistive intervention. The feasibility and efficacy of the proposed framework are evaluated by conducting an experiment involving a healthy adult with cerebral palsy symptoms being induced using transcutaneous electrical nerve stimulation.

Video-assisted versus conventional thoracotomy pneumonectomy: a comparison of perioperative outcomes and short-term measures of convalescence.

PubMed

Liu, Yuanqi; Gao, Yang; Zhang, Huajun; Cheng, Yuanda; Chang, Ruimin; Zhang, Weixing; Zhang, Chunfang

2016-12-01

Pneumonectomy is a proven treatment for lung diseases. We sought to present a comparison between video-assisted thoracic surgery pneumonectomy (VATS-P) and conventional thoracotomy pneumonectomy (CP) on perioperative outcomes and short-term measures of convalescence. A retrospective cohort study was performed to assess perioperative outcomes among patients underwent VATS-P and CP. A total of 32 patients undergoing VATS-P were matched 2:1 about comorbidity, surgical indication, tumour size and lesion location to a previous cohort of 64 patients who underwent CP. Demographic and perioperative data were obtained. Statistical analysis was performed. Mean patient age was 55.4 years for both groups, with equal sex distribution. Pneumonectomy for malignant and benign lesion patients was evaluated individually. For malignant tumour patients, median tumour size was 3.9 cm for both groups. There was no difference between VATS-P and CP cases in transfusion rates (2% vs. 10%, P=0.50), dissected lymph node numbers (11.9 vs. 14.2, P=0.26), dissected lymph node stations (5.0 vs. 4.9, P=0.75), estimated blood loss (226.0 vs. 261.3 mL, P=0.40), complication rate (20.0% vs. 22.5%, P=0.82), postoperative drainage time (5.9 vs. 6.2, P=0.50) or length of hospital stay (7.5 vs. 8.1, P=0.50). Operation time in VATS-P was higher than conventional groups (187.5 vs. 146.3 min, P=0.00) but the mean pain score was significantly less. For benign patients, over 1,000 mL blood losing (1,033.3 vs. 1,233.3 mL, P=0.78) and 180 minutes (186.6 vs. 105.8, P=0.73) OR time was found in both groups. The Length of stay (7.6 vs. 6.3 d, P=0.57), transfusion rates (66.7% vs. 33.3%), complications rates (zero in both group) and length of drainage (6.7 vs. 6.7 d, P=1.0) between two groups are identical. Complete video-assisted thoracic surgery (VATS) pneumonectomy is feasible and safe technique and can be recommended as a surgical treatment for lung cancer patients. However, long-term benefits need to be evaluated by further studies and large sample tests.

Robot-assisted laparoscopic versus open partial nephrectomy in patients with chronic kidney disease: A propensity score-matched comparative analysis of surgical outcomes.

PubMed

Takagi, Toshio; Kondo, Tsunenori; Tachibana, Hidekazu; Iizuka, Junpei; Omae, Kenji; Kobayashi, Hirohito; Yoshida, Kazuhiko; Tanabe, Kazunari

2017-07-01

To compare surgical outcomes between robot-assisted laparoscopic partial nephrectomy and open partial nephrectomy in patients with chronic kidney disease. Of 550 patients who underwent partial nephrectomy between 2012 and 2015, 163 patients with T1-2 renal tumors who had an estimated glomerular filtration rate between 30 and 60 mL/min/1.73 m 2 , and underwent robot-assisted laparoscopic partial nephrectomy or open partial nephrectomy were retrospectively analyzed. To minimize selection bias between the two surgical methods, patient variables were adjusted by 1:1 propensity score matching. The present study included 75 patients undergoing robot-assisted laparoscopic partial nephrectomy and 88 undergoing open partial nephrectomy. After propensity score matching, 40 patients were included in each operative group. The mean preoperative estimated glomerular filtration rate was 49 mL/min/1.73 m 2 . The mean ischemia time was 21 min in robot-assisted laparoscopic partial nephrectomy (warm ischemia) and 35 min in open partial nephrectomy (cold ischemia). Preservation of the estimated glomerular filtration rate 3-6 months postoperatively was not significantly different between robot-assisted laparoscopic partial nephrectomy and open partial nephrectomy (92% vs 91%, P = 0.9348). Estimated blood loss was significantly lower in the robot-assisted laparoscopic partial nephrectomy group than in the open partial nephrectomy group (104 vs 185 mL, P = 0.0025). The postoperative length of hospital stay was shorter in the robot-assisted laparoscopic partial nephrectomy group than in the open partial nephrectomy group (P < 0.0001). The prevalence of Clavien-Dindo grade 3 complications and a negative surgical margin status were not significantly different between the two groups. In our experience, robot-assisted laparoscopic partial nephrectomy and open partial nephrectomy provide similar outcomes in terms of functional preservation and perioperative complications among patients with chronic kidney disease. However, a lower estimated blood loss and shorter postoperative length of hospital stay can be obtained with robot-assisted laparoscopic partial nephrectomy. © 2017 The Japanese Urological Association.

Knowledge assistant for robotic environmental characterization

DOE Office of Scientific and Technical Information (OSTI.GOV)

Feddema, J.; Rivera, J.; Tucker, S.

1996-08-01

A prototype sensor fusion framework called the {open_quotes}Knowledge Assistant{close_quotes} has been developed and tested on a gantry robot at Sandia National Laboratories. This Knowledge Assistant guides the robot operator during the planning, execution, and post analysis stages of the characterization process. During the planning stage, the Knowledge Assistant suggests robot paths and speeds based on knowledge of sensors available and their physical characteristics. During execution, the Knowledge Assistant coordinates the collection of data through a data acquisition {open_quotes}specialist.{close_quotes} During execution and postanalysis, the Knowledge Assistant sends raw data to other {open_quotes}specialists,{close_quotes} which include statistical pattern recognition software, a neural network,more » and model-based search software. After the specialists return their results, the Knowledge Assistant consolidates the information and returns a report to the robot control system where the sensed objects and their attributes (e.g., estimated dimensions, weight, material composition, etc.) are displayed in the world model. This report highlights the major components of this system.« less

Control of robot assistant for rehabilitation of upper extremities.

PubMed

Kostić, Miloš D; Popović, Mirjana B; Popović, Dejan B

2012-01-01

The assisted movement in humans with paresis of upper extremities is becoming popular for neurorehabilitation. We propose a novel method for trajectory selection and assistance control. This paper presents simulation of a planar two degrees of freedom robot that assists horizontal movement of the hand. The control assumes that during the exercise the hand needs to follow healthy alike trajectories. The robot is assumed to provide minimal assistance and operate as a teacher of the movement.

Robotic Assistance for Training Finger Movement Using a Hebbian Model: A Randomized Controlled Trial.

PubMed

Rowe, Justin B; Chan, Vicky; Ingemanson, Morgan L; Cramer, Steven C; Wolbrecht, Eric T; Reinkensmeyer, David J

2017-08-01

Robots that physically assist movement are increasingly used in rehabilitation therapy after stroke, yet some studies suggest robotic assistance discourages effort and reduces motor learning. To determine the therapeutic effects of high and low levels of robotic assistance during finger training. We designed a protocol that varied the amount of robotic assistance while controlling the number, amplitude, and exerted effort of training movements. Participants (n = 30) with a chronic stroke and moderate hemiparesis (average Box and Blocks Test 32 ± 18 and upper extremity Fugl-Meyer score 46 ± 12) actively moved their index and middle fingers to targets to play a musical game similar to GuitarHero 3 h/wk for 3 weeks. The participants were randomized to receive high assistance (causing 82% success at hitting targets) or low assistance (55% success). Participants performed ~8000 movements during 9 training sessions. Both groups improved significantly at the 1-month follow-up on functional and impairment-based motor outcomes, on depression scores, and on self-efficacy of hand function, with no difference between groups in the primary endpoint (change in Box and Blocks). High assistance boosted motivation, as well as secondary motor outcomes (Fugl-Meyer and Lateral Pinch Strength)-particularly for individuals with more severe finger motor deficits. Individuals with impaired finger proprioception at baseline benefited less from the training. Robot-assisted training can promote key psychological outcomes known to modulate motor learning and retention. Furthermore, the therapeutic effectiveness of robotic assistance appears to derive at least in part from proprioceptive stimulation, consistent with a Hebbian plasticity model.

Virtual modeling of robot-assisted manipulations in abdominal surgery.

PubMed

Berelavichus, Stanislav V; Karmazanovsky, Grigory G; Shirokov, Vadim S; Kubyshkin, Valeriy A; Kriger, Andrey G; Kondratyev, Evgeny V; Zakharova, Olga P

2012-06-27

To determine the effectiveness of using multidetector computed tomography (MDCT) data in preoperative planning of robot-assisted surgery. Fourteen patients indicated for surgery underwent MDCT using 64 and 256-slice MDCT. Before the examination, a specially constructed navigation net was placed on the patient's anterior abdominal wall. Processing of MDCT data was performed on a Brilliance Workspace 4 (Philips). Virtual vectors that imitate robotic and assistant ports were placed on the anterior abdominal wall of the 3D model of the patient, considering the individual anatomy of the patient and the technical capabilities of robotic arms. Sites for location of the ports were directed by projection on the roentgen-positive tags of the navigation net. There were no complications observed during surgery or in the post-operative period. We were able to reduce robotic arm interference during surgery. The surgical area was optimal for robotic and assistant manipulators without any need for reinstallation of the trocars. This method allows modeling of the main steps in robot-assisted intervention, optimizing operation of the manipulator and lowering the risk of injuries to internal organs.

Robotic assisted andrological surgery

PubMed Central

Parekattil, Sijo J; Gudeloglu, Ahmet

2013-01-01

The introduction of the operative microscope for andrological surgery in the 1970s provided enhanced magnification and accuracy, unparalleled to any previous visual loop or magnification techniques. This technology revolutionized techniques for microsurgery in andrology. Today, we may be on the verge of a second such revolution by the incorporation of robotic assisted platforms for microsurgery in andrology. Robotic assisted microsurgery is being utilized to a greater degree in andrology and a number of other microsurgical fields, such as ophthalmology, hand surgery, plastics and reconstructive surgery. The potential advantages of robotic assisted platforms include elimination of tremor, improved stability, surgeon ergonomics, scalability of motion, multi-input visual interphases with up to three simultaneous visual views, enhanced magnification, and the ability to manipulate three surgical instruments and cameras simultaneously. This review paper begins with the historical development of robotic microsurgery. It then provides an in-depth presentation of the technique and outcomes of common robotic microsurgical andrological procedures, such as vasectomy reversal, subinguinal varicocelectomy, targeted spermatic cord denervation (for chronic orchialgia) and robotic assisted microsurgical testicular sperm extraction (microTESE). PMID:23241637

Hybrid procedure for total laryngectomy with a flexible robot-assisted surgical system.

PubMed

Schuler, Patrick J; Hoffmann, Thomas K; Veit, Johannes A; Rotter, Nicole; Friedrich, Daniel T; Greve, Jens; Scheithauer, Marc O

2017-06-01

Total laryngectomy is a standard procedure in head-and-neck surgery for the treatment of cancer patients. Recent clinical experiences have indicated a clinical benefit for patients undergoing transoral robot-assisted total laryngectomy (TORS-TL) with commercially available systems. Here, a new hybrid procedure for total laryngectomy is presented. TORS-TL was performed in human cadavers (n = 3) using a transoral-transcervical hybrid procedure. The transoral approach was performed with a robotic flexible robot-assisted surgical system (Flex®) and compatible flexible instruments. Transoral access and visualization of anatomical landmarks were studied in detail. Total laryngectomy is feasible with a combined transoral-transcervical approach using the flexible robot-assisted surgical system. Transoral visualization of all anatomical structures is sufficient. The flexible design of the robot is advantageous for transoral surgery of the laryngeal structures. Transoral robot assisted surgery has the potential to reduce morbidity, hospital time and fistula rates in a selected group of patients. Initial clinical studies and further development of supplemental tools are in progress. Copyright © 2016 John Wiley & Sons, Ltd. Copyright © 2016 John Wiley & Sons, Ltd.

Hand gesture guided robot-assisted surgery based on a direct augmented reality interface.

PubMed

Wen, Rong; Tay, Wei-Liang; Nguyen, Binh P; Chng, Chin-Boon; Chui, Chee-Kong

2014-09-01

Radiofrequency (RF) ablation is a good alternative to hepatic resection for treatment of liver tumors. However, accurate needle insertion requires precise hand-eye coordination and is also affected by the difficulty of RF needle navigation. This paper proposes a cooperative surgical robot system, guided by hand gestures and supported by an augmented reality (AR)-based surgical field, for robot-assisted percutaneous treatment. It establishes a robot-assisted natural AR guidance mechanism that incorporates the advantages of the following three aspects: AR visual guidance information, surgeon's experiences and accuracy of robotic surgery. A projector-based AR environment is directly overlaid on a patient to display preoperative and intraoperative information, while a mobile surgical robot system implements specified RF needle insertion plans. Natural hand gestures are used as an intuitive and robust method to interact with both the AR system and surgical robot. The proposed system was evaluated on a mannequin model. Experimental results demonstrated that hand gesture guidance was able to effectively guide the surgical robot, and the robot-assisted implementation was found to improve the accuracy of needle insertion. This human-robot cooperative mechanism is a promising approach for precise transcutaneous ablation therapy. Copyright © 2013 Elsevier Ireland Ltd. All rights reserved.

Effect of Caregiver Driven Robot-Assisted In-Ward Training in Subacute Stroke Patients: A Case Series

PubMed Central

2018-01-01

Objective To evaluate the effect of caregiver driven robot-assisted in-ward training in subacute stroke patients. Methods A retrospective evaluation was performed for patients treated with caregiver driven robot-assisted in-ward training to retain gait function from June 2014 and December 2016. All patients received more than 2 weeks of caregiver driven robot-assisted in-ward training after undergoing conventional programs. The robot was used as a sitting device, a standing frame, or a high-walker depending on functional status of the patient. Patients were evaluated before and after robot training. Patient records were assessed by Korean version of Modified Barthel Index (K-MBI), Functional Independence Measure (FIM), and Functional Ambulation Category (FAC). Results Initially, patients used the robot as a sitting device (n=6), a standing frame (n=7), or a partial body-weight support high-walker (n=2). As patient functions were improved, usage level of the robot was changed to the next level. At the end of the treatment, the robot was used as a sitting device (n=1), a standing frame (n=6), or high-walker (n=8). Scores of K-MBI (Δ17.47±10.72) and FIM (Δ19.80±12.34) were improved in all patients. Conclusion Patients' usage level of the robot and functional scores were improved. Therefore, performing additional caregiver driven robot-assisted in-ward training is feasible and beneficial for subacute stroke patients. PMID:29765872

Effect of Caregiver Driven Robot-Assisted In-Ward Training in Subacute Stroke Patients: A Case Series.

PubMed

Kim, Sang Beom; Lee, Kyeong Woo; Lee, Jong Hwa; Lee, Sook Joung; Park, Jin Gee; Park, Joo Won

2018-04-01

To evaluate the effect of caregiver driven robot-assisted in-ward training in subacute stroke patients. A retrospective evaluation was performed for patients treated with caregiver driven robot-assisted in-ward training to retain gait function from June 2014 and December 2016. All patients received more than 2 weeks of caregiver driven robot-assisted in-ward training after undergoing conventional programs. The robot was used as a sitting device, a standing frame, or a high-walker depending on functional status of the patient. Patients were evaluated before and after robot training. Patient records were assessed by Korean version of Modified Barthel Index (K-MBI), Functional Independence Measure (FIM), and Functional Ambulation Category (FAC). Initially, patients used the robot as a sitting device (n=6), a standing frame (n=7), or a partial body-weight support high-walker (n=2). As patient functions were improved, usage level of the robot was changed to the next level. At the end of the treatment, the robot was used as a sitting device (n=1), a standing frame (n=6), or high-walker (n=8). Scores of K-MBI (Δ17.47±10.72) and FIM (Δ19.80±12.34) were improved in all patients. Patients' usage level of the robot and functional scores were improved. Therefore, performing additional caregiver driven robot-assisted in-ward training is feasible and beneficial for subacute stroke patients.

Assessing the risk of pelvic and para-aortic nodal involvement in apparent early-stage ovarian cancer: A predictors- and nomogram-based analyses.

PubMed

Bogani, Giorgio; Tagliabue, Elena; Ditto, Antonino; Signorelli, Mauro; Martinelli, Fabio; Casarin, Jvan; Chiappa, Valentina; Dondi, Giulia; Leone Roberti Maggiore, Umberto; Scaffa, Cono; Borghi, Chiara; Montanelli, Luca; Lorusso, Domenica; Raspagliesi, Francesco

2017-10-01

To estimate the prevalence of lymph node involvement in early-stage epithelial ovarian cancer in order to assess the prognostic value of lymph node dissection. Data of consecutive patients undergoing staging for early-stage epithelial ovarian cancer were retrospectively evaluated. Logistic regression and a nomogram-based analysis were used to assess the risk of lymph node involvement. Overall, 290 patients were included. All patients had lymph node dissection including pelvic and para-aortic lymphadenectomy. Forty-two (14.5%) patients were upstaged due to lymph node metastatic disease. Pelvic and para-aortic nodal metastases were observed in 22 (7.6%) and 42 (14.5%) patients. Lymph node involvement was observed in 18/95 (18.9%), 1/37 (2.7%), 4/29 (13.8%), 11/63 (17.4%), 3/41 (7.3%) and 5/24 (20.8%) patients with high-grade serous, low-grade-serous, endometrioid G1, endometrioid G2&3, clear cell and undifferentiated, histology, respectively (p=0.12, Chi-square test). We observed that high-grade serous histology was associated with an increased risk of pelvic node involvement; while, histology rather than low-grade serous and bilateral tumors were independently associated with para-aortic lymph node involvement (p<0.05). Nomograms displaying the risk of nodal involvement in the pelvic and para-aortic areas were built. High-grade serous histology and bilateral tumors are the main characteristics suggesting lymph node positivity. Our data suggested that high-grade serous and bilateral early-stage epithelial ovarian cancer are at high risk of having disease harboring in the lymphatic tissues of both pelvic and para-aortic area. After receiving external validation, our data will help to identify patients deserving comprehensive retroperitoneal staging. Copyright © 2017 Elsevier Inc. All rights reserved.

EEG Analysis During Active and Assisted Repetitive Movements: Evidence for Differences in Neural Engagement.

PubMed

Tacchino, Giulia; Gandolla, Marta; Coelli, Stefania; Barbieri, Riccardo; Pedrocchi, Alessandra; Bianchi, Anna M

2017-06-01

Two key ingredients of a successful neuro-rehabilitative intervention have been identified as intensive and repetitive training and subject's active participation, which can be coupled in an active robot-assisted training. To exploit these two elements, we recorded electroencephalography, electromyography and kinematics signals from nine healthy subjects performing a 2×2 factorial design protocol, with subject's volitional intention and robotic glove assistance as factors. We quantitatively evaluated primary sensorimotor, premotor and supplementary motor areas activation during movement execution by computing event-related desynchronization (ERD) patterns associated to mu and beta rhythms. ERD patterns showed a similar behavior for all investigated regions: statistically significant ERDs began earlier in conditions requiring subject's volitional contribution; ERDs were prolonged towards the end of movement in conditions in which the robotic assistance was present. Our study suggests that the combination between subject volitional contribution and movement assistance provided by the robotic device (i.e., active robot-assisted modality) is able to provide early brain activation (i.e., earlier ERD) associated with stronger proprioceptive feedback (i.e., longer ERD). This finding might be particularly important for neurological patients, where movement cannot be completed autonomously and passive/active robot-assisted modalities are the only possibilities of execution.

Does a uterine manipulator affect cervical cancer pathology or identification of lymphovascular space involvement?

PubMed

Rakowski, Joseph A; Tran, Tien Anh N; Ahmad, Sarfraz; James, Jeffrey A; Brudie, Lorna A; Pernicone, Peter J; Radi, Michael J; Holloway, Robert W

2012-10-01

Uterine manipulators are a useful adjunct for robotic-assisted radical hysterectomy (RARH), but some surgeons avoid their use for fear of altering pathology or interpretation of lymphovascular space involvement (LVSI). We retrospectively compared clinico-pathological data and tumor pathology from patients with cervical cancer operated by laparotomy vs. RARH. Charts from cervical cancer patients who underwent radical hysterectomy from January-1997 to June-2010 were reviewed for tumor histology, grade, FIGO stage, lymph node status, LVSI, depth of invasion, and tumor size. A ConMed V-Care® uterine manipulator was used in all robotic cases. H&E stained slides from 20 robotic and 24 open stage IB1 cases with LVSI reported in the original pathology were re-reviewed by a blinded pathologist for analysis of tissue artifacts and LVSI. Two-hundred-thirty-six cases (185 open, 51 robotic) with stages IA2, IB1 and IB2 cervical cancer were reviewed. No significant differences in histology (squamous cell carcinoma, 65% vs. 51%; p=0.1), IB1 lesion size (≤2 cm, 62% vs. 61%, p>0.1), LVSI (34% vs. 39%, p>0.1), and depth of stromal invasion (p>0.1) was found between open and robotic groups. Histologic examination of all IB1 cervical carcinomas revealed a higher degree of surface disruption [45% (9/20) vs. 12.6% (3/24), p=0.038] and artifactual "parametrial carryover" [65% (13/20) vs. 29% (7/24), p=0.037] in robotic vs. open groups, respectively, but no significant differences in the rate of LVSI. RARH cases that utilized a uterine manipulator did not show any clinico-pathological differences in depth of invasion, LVSI, or parametrial involvement compared to open cases. Copyright © 2012 Elsevier Inc. All rights reserved.

[A Case of Liver Metastasis from Esophageal Cancer Successfully Treated by Surgical Resection after Chemotherapy with Weekly-Paclitaxel].

PubMed

Nozawa, Akinori; Kubo, Naoshi; Shimizu, Sadatoshi; Murata, Akihiro; Kanazawa, Akishige; Kodai, Shintaro; Urata, Yorihisa; Miura, Kotaro; Tauchi, Jun; Sakurai, Katsunori; Tachimori, Akiko; Tamamori, Yutaka; Inoue, Toru; Yamashita, Yoshito; Nishiguchi, Yukio

2017-11-01

A 58-year-old man complaining of dysphagia was admitted to our hospital and diagnosed with esophageal cancer.He underwent thoracoscopic subtotal esophagectomy with 3-field lymph node dissection and reconstruction with a gastric tube created by hand-assisted laparoscopy.The pathological diagnosis was classified as AeLtG, pT3N2M0, pStage III .He was subsequently treated with systemic chemotherapy with 5-fluorouracil and cisplatin.After 2 courses, a single liver metastatic tumor appeared at segment 5.As chemotherapy against the recurrence, weekly-paclitaxel was administered.After 2 courses, the metastatic liver tumor reduced in size.Subsequently, laparoscopic partial liver resection was performed 11 months after first surgery.The pathological finding was negative for malignancy(pathological complete response).

[Systematization of proper lymphatic vessels of the diaphragm].

PubMed

Okiemy, G; Ele, N; Itoua, C; Avisse, C; Riquet, M; Hidden, G

2006-01-01

The aim of this study was to demonstrate lymphatic vessels of the diaphragm, its connexions with mediastinum and abdominal cavity in order to better understand propagation of neoplasic or infectious processes. Diaphragmatic pleura of 30 adult cadavers and 12 fetuses, unscathed of any cardiopulmonary pathology, were injected with modified Gerota's medium to permit lymph vessels and nodes to be visualized and then dissected. Each stage of dissection was described and photographed. Diaphragmatic lymph vessels, their connexions with diaphragmatic lymph nodes, mediastinum and abdominal cavity have been so demonstrated. Diaphragm appear to be a very important lymphatic center, with its own lymphatic vessels, with connexions to the mediastinum and abdominal cavity. The propagation of infectious or neoplasic processes are so better understood.

Uncut Roux-en-Y reconstruction after totally laparoscopic distal gastrectomy with D2 lymph node dissection for early stage gastric cancer.

PubMed

Huang, Hua; Long, Ziwen; Xuan, Yi

2016-01-01

Roux Stasis Syndrome is a well-known complication after Roux-en-Y reconstruction. Uncut Roux-en-Y technique, would preserve unidirectional intestinal myoelectrical activity and diminish Roux Stasis Syndrome. A 61 years old woman with moderately differentiated adenocarcinoma of antrum who was diagnosed by gastroscopy and histological test, underwent totally laparoscopic distal gastrectomy (TLDG) with D2 lymph node dissection and uncut Roux-en-Y reconstruction (URYR). The length of operation was 190 min with bleeding of about 40 mL. The patient recovers well postoperation and discharged from hospital on the 7 th day. TLDG with intracorporeal uncut Roux-en-Y gastrojejunostomies using laparoscopic linear staplers was safe and feasible with minimal invasiveness.

The immediate effects of robot-assistance on energy consumption and cardiorespiratory load during walking compared to walking without robot-assistance: a systematic review.

PubMed

Lefeber, Nina; Swinnen, Eva; Kerckhofs, Eric

2017-10-01

The integration of sufficient cardiovascular stress into robot-assisted gait (RAG) training could combine the benefits of both RAG and aerobic training. The aim was to summarize literature data on the immediate effects of RAG compared to walking without robot-assistance on metabolic-, cardiorespiratory- and fatigue-related parameters. PubMed and Web of Science were searched for eligible articles till February 2016. Means, SDs and significance values were extracted. Effect sizes were calculated. Fourteen studies were included, concerning 155 participants (85 healthy subjects, 39 stroke and 31 spinal cord injury patients), 9 robots (2 end-effectors, 1 treadmill-based and 6 wearable exoskeletons), and 7 outcome parameters (mostly oxygen consumption and heart rate). Overall, metabolic and cardiorespiratory parameters were lower during RAG compared to walking without robot-assistance (moderate to large effect sizes). In healthy subjects, when no body-weight support (BWS) was provided, RAG with an end-effector device was more energy demanding than walking overground (p > .05, large effect sizes). Generally, results suggest that RAG is less energy-consuming and cardiorespiratory stressful than walking without robot-assistance, but results depend on factors such as robot type, walking speed, BWS and effort. Additional research is needed to draw firm conclusions. Implications for Rehabilitation Awareness of the energy consumption and cardiorespiratory load of robot-assisted gait (RAG) training is important in the rehabilitation of (neurological) patients with impaired cardiorespiratory fitness and patients who are at risk of cardiovascular diseases. On the other hand, the integration of sufficient cardiometabolic stress in RAG training could combine the effects of both RAG and aerobic training. Energy consumption and cardiorespiratory load during walking with robot-assistance seems to depend on factors such as robot type, walking speed, body-weight support or amount of effort. These parameters could be adjusted in RAG rehabilitation to make RAG more or less energy-consuming and cardiorespiratory stressful. Overall, short duration exoskeleton walking seems less energy-consuming and cardiorespiratory stressful than walking without robot-assistance. This might implicate that the exercise intensity is safe for (neurological) patients at risk of cardiovascular diseases. How this changes in extended walking time is unclear.

The utility of intraoperative ultrasound in modified radical neck dissection: a pilot study.

PubMed

Agcaoglu, Orhan; Aliyev, Shamil; Taskin, Halit Eren; Aksoy, Erol; Siperstein, Allan; Berber, Eren

2014-04-01

Although the value of surgeon-performed neck ultrasound (SPUS) for thyroid nodules has been validated, the utility of intraoperative ultrasound (US) in modified radical neck dissection (MRND) has not been reported in the literature. The aim of this study was to analyze the utility of intraoperative SPUS in assessing the completeness of MRND for thyroid cancer. Between 2007 and 2011, a total of 25 patients underwent MRND by 1 surgeon for thyroid cancer. All patients underwent intraoperative SPUS, which was repeated at the end of the neck dissection (completion US) to look for missed lymph nodes (LNs). There were 10 male and 15 female patients. Pathology included 23 papillary and 2 medullary carcinomas. The number of LNs removed per case was 23 ± 2, and the number of positive was LNs 5 ± 1. In 4 (16%) cases, intraoperative US detected 7 residual LNs, which would have been missed, if completion US were not done. These missed LNs were located in low-level IV (3 nodes), high-level II (2 nodes), and posterior level V (2 nodes) and measured 1.4 ± 0.2 cm. At follow-up, recurrence was seen in 2 (8%) patients, including a superior mediastinal recurrence in a patient with tall cell cancer and a jugular LN recurrence at level II in another patient with papillary thyroid cancer. This pilot study shows that intraoperative SPUS can help assess the completeness of MRND. According to our results, intraoperative completion US identifies LNs missed by palpation 16% of the time.