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INTRODUCTION: Post-operative prescription opioid use is a known risk factor for persistent opioid use. Despite the increased utilization of robotic-assisted surgery (RAS) for inguinal hernia repair (IHR), little is known whether this minimally invasive approach results in less opioid consumption. In this study, we compare long-term opioid use between RAS versus laparoscopic (Lap) versus open surgery for IHR. METHODS: A retrospective cohort study of opioid-naïve patients who underwent outpatient primary IHR was conducted using the Merative™ MarketScan® (Previously IBM MarketScan®) Databases between 2016 and 2020. Patients not continuously enrolled 180 days before/after surgery, who had malignancy, pre-existing chronic pain, opioid dependency, or invalid prescription fill information were excluded. Among patients exposed to opioids peri-operatively, we assessed long-term opioid use as any opioid prescription fill within 90 to 180 days post-surgery. Secondary outcomes were controlled substance schedule II/III opioid fill, and high-dose opioid fill defined as > 50 morphine milligram equivalent per day. An Inverse-probability of treatment weighted logistic regression was used to compare outcomes between groups with p-value of

BACKGROUND: The field of robotic-assisted surgery is rapidly growing as many robotic surgical devices are in development and about to enter the market. Currently, there is no universally accepted language for labeling the different robotic systems. To facilitate this communication, we created what is, to our knowledge, the first classification of surgical robotic technologies that organizes and classifies surgical robots used for endoscopy, laparoscopy and thoracoscopy. METHODS: We compiled a list of surgical robots intended to be used for endoscopy, laparoscopy, and/or thoracoscopy by searching United States, European, Hong Kong, Japan, and Korean databases for approved devices. Devices showcased at the 2023 Annual Meeting for the Society of Robotic Surgery were added. We also systematically reviewed the literature for any existing surgical robotic classifications or categorizations. We then created a multidisciplinary committee of 8 surgeons and 2 engineers to construct a proposed classification of the devices included in our search. RESULTS: We identified 40 robotic surgery systems intended to be used for endoscopy, laparoscopy and/or thoracoscopy. The proposed classification organizes robotic devices with regard to architecture, port design, and configuration (modular carts, multi-arm integrated cart, table-attachable or arm-table integration). CONCLUSION: This 3-level classification of robotic surgical devices used for endoscopy, laparoscopy and/or thoracoscopy describes important characteristics of robotic devices systematically.

BackgroundNo platform for objective, synchronous and on-line evaluation of both intraoperative error and surgeon physiology yet exists. Electrokardiogram (EKG) metrics have been associated with cognitive and affective features that are known to impact surgical performance but have not yet been analyzed in conjunction with real-time error signals using objective, real-time methods.MethodsEKGs and operating console point-of-views (POVs) for fifteen general surgery residents and five non-medically trained participants were captured during three simulated robotic-assisted surgery (RAS) procedures. Time and frequency-domain EKG statistics were extracted from recorded EKGs. Intraoperative errors were detected from operating console POV videos. EKG statistics were synchronized with intraoperative error signals.ResultsRelative to personalized baselines, IBI, SDNN and RMSSD decreased 0.15% (S.E. 3.603e-04; P = 3.25e-05), 3.08% (S.E. 1.603e-03; P

BackgroundFrom clinical experience, many patients undergoing robotic assisted surgery (RAS) have a poor understanding of the technology. To ensure informed consent and appropriate expectations, a needs assessment for patient-centered education and outcome metrics in RAS is warranted. Our goal was to perform an assessment of patient understanding, comfort with robotic technology, and ability to obtain critical information from their surgeon when undergoing RAS.MethodsTwenty patients planned for RAS by three surgeons were asked to complete a six-item Likert agreement scale survey prior to signing informed consent. The study coordinator administered surveys, while the surgeon left the room. Indicator statements were crafted to reduce bias and two-way evaluated for consistency. The surgeons were additionally asked their perception of each patient's understanding and comfort with RAS. Frequency statistics and tendencies were analyzed.ResultsSurgeons strongly agreed all patients appropriately understood how RAS functioned and would ask more questions before signing consent, if needed. Patients were predominately not familiar with RAS and felt surgeons did not explain how RAS worked. There was wide variability on if patients understood how RAS worked for their treatment. Overall, patients were not completely comfortable with RAS for their care, did not understand the risks of RAS compared to other approaches, and did not feel their surgeon understood what they needed to know to make informed decisions.ConclusionsThis needs assessment demonstrated critical gaps in patient knowledge about RAS, surgeon communication skills, and the ability of surgeons to know what was important from the patient perspective. The development of RAS patient-centered education and outcome metrics could help address these gaps.

BackgroundPerineal hernias can be secondarily acquired following abdominoperineal resection of the rectum. While transabdominal minimally invasive techniques have traditionally used laparoscopy, there are few studies published on the robotic platform, which has been gaining popularity for other types of hernia repairs. We review the existing literature, share a video vignette, and provide practical tips for surgeons interested in adopting this approach.MethodsA literature search in Pubmed was performed to include all articles in English describing robotic repair of perineal hernias with identification of variables of interest related to repair. A case presentation with an accompanying video vignette and lessons learned from the experience are provided.ResultsSeven case reports (four containing video) published between 2019 and 2022 were included. Most articles (n = 5) utilized the Da Vinci Si or Xi, and most patients (n = 5) had undergone abdominoperineal resection with neoadjuvant chemotherapy to treat rectal cancer. Patients were positioned in Trendelenburg with rightward tilt (n = 2), modified lithotomy (n = 1), or a combination of the two (n = 1). All articles (n = 7) reported closing the defect and using mesh. Three articles describe placing five ports (one camera, three robotic, one assistant). There were no significant intraoperative or postoperative complications reported, and no recurrence noted at 3-27 months follow-up. Based on our experience, as shown in the video vignette, we recommend lithotomy positioning, using porous polypropylene mesh anchored to the periosteum of the sacrum and peritoneum overlying the bladder and side wall, and placing a drain above the mesh.ConclusionsA robotic transabdominal approach to perineal hernia repair is a viable alternate to laparoscopy based on low complication rates and lack of recurrence. Prospective and longer duration data are needed to compare the techniques.

BackgroundAlthough there is extensive literature on robotic total intracorporeal anastomosis (TICA) for right colon resection, left total ICA using the da Vinci Xi robotic platform has only been described in short case series previously. In this study, we report on the largest cohort of robotic left total ICA, provide a description of our institution's techniques, and compare outcomes to robotic left partial extracorporeal anastomosis (PECA).MethodsPatients who underwent robotic left colectomy for any underlying pathology from July 1, 2016 through April 30, 2020 were identified by procedure code. A technical description is provided for two unique techniques performed at our institution. Outcomes included operative time, length of stay, supply cost, post-operative ileus, post-operative morbidity and mortality and need for complete mobilization of the splenic flexure.ResultsFrom a review of our institution's data, 83 robotic TICA cases were identified and 76 robotic PECA cases were identified. Common procedures included low anterior resection, sigmoidectomy, left hemicolectomy, and rectopexy with resection. TICA was associated with significantly shorter intraoperative time compared to PECA.ConclusionsOur series shows that TICA is a safe and feasible technique that does not increase the risk of adverse outcomes. Using either the anvil-forward or anvil-backward technique, we were able to reliably reproduce this method in a total of 83 patients undergoing left colon resection for either benign or malignant diseases.

BackgroundFew studies have examined robotic surgery from a programmatic standpoint, yet this is how hospitals evaluate return on investment clinically and fiscally. This study examines the 10-year experience of a robotic program at a single academic institution.Study designAll robotic operations performed at our institution from August 2005 to December 2016 were reviewed. Data were collected from the robotic system and hospital databases.ResultsA total of 3485 robotic operations were performed. Yearly case volume nearly quadrupled. There have been 37 robotic-trained surgeons in 5 specialties performing 53 different operations. Rate of conversion to open was 4.2%. American Society of Anesthesiologists (ASA) class increased over time, with ASA class 3 increasing from 20% of patients to 45% of patients. Average case time in 2005 was 453 min, but decreased by 46% to 246 min by 2007, then remained relatively stable (range 226-247). Operating efficiency improved, with room time and case time decreasing by 9% in the past 4 years. Average cost for robotic supplies was $1519 per case. Additional costs per case related to equipment and contracts totaled an average of $11,822. Average length of stay (LOS) for robotic cases was 3.3 days, compared to 3.0 days for laparoscopic and 7.0 for open. Cost per day for admission after robotic surgery was 1.7 times greater than the cost of open or laparoscopic surgery. Total admission costs of robotic operations were 1.5 times those of laparoscopic surgery, but less than open operations. Readmissions following robotic cases were lower than open (15% v 26%, p

BackgroundWe investigated a novel minimally invasive surgical platform for use in the oropharynx, hypopharynx, and larynx for single-port transoral surgery used in concert with standard transoral laryngeal and pharyngeal instrumentation.MethodsThe preclinical investigational device by Fortimedix Surgical B.V. (Netherlands) features two channels for manually controlled flexible articulating surgical instruments. A third central channel accepts both rigid and flexible endoscopes. The system is coupled to a standard laryngoscope for transoral access. In three cadaver models, we evaluated the surgical capabilities using wristed grasping instruments, microlaryngeal scissors, monopolar cautery, and a laser fiber sheath. Procedures were performed within the oropharynx, supraglottis, glottis, subglottis, and hypopharynx.ResultsWithin the oropharynx, we found adequate strength, range of motion, and dexterity to perform lateral oropharyngectomy and tongue base resection. Within the larynx, visualization was achieved with a variety of instruments including a flexible, 0° and 30° rigid endoscope. The glottis, supraglottis, pyriform sinuses, post-cricoid space, and esophageal inlet were readily accessible. Visualization and manipulation of grasping, laser, and monopolar cautery instruments were also possible within the subglottis. Instrument reach and accuracy facilitated completion of a delicate micro-flap on the true vocal fold. Other procedures included vocal fold resection, cricopharyngeal myotomy, and resection of subglottic mucosa.ConclusionsFrom this initial proof of concept experience with this novel platform, we found a wide range of procedures within the oropharynx, larynx, and hypopharynx to be feasible. Further work is needed to evaluate its applicability to the clinical setting. The ability of this platform to be used with conventional instrumentation may provide an opportunity for complex transoral surgery to be performed in a facile manner at greatly reduced cost.

BackgroundCommon colorectal procedures that require access to all quadrants of the abdomen are subtotal colectomy (STC) and total proctocolectomy (TPC). These are frequently performed with a surgical robot, but multiquadrant operations have unique challenges during robot-assisted surgery.MethodsPatients who underwent robotic STC or TPC with the da Vinci Xi surgical robot at our institution from July 1, 2016 through June 30, 2019 were identified by diagnosis and procedure codes. A technical description is provided for the techniques utilized at our institution. Outcomes included operative times (OT), supply cost and length of stay. Associated morbidity and mortality was also analyzed.ResultsFrom a review of our institution's robotic surgery data, 37 cases were identified that utilized the described technique. Of these cases, 21 were robotic STC and 16 were TPC. Total mean OT was 276.86 min (SD ± 119.49). Mean OT was further analyzed by year, which demonstrated an overall decrease in OT from 350.91 min (SD ± 46.38) in 2016 to 221.43 min (SD ± 16.46) in 2018 (p = 0.008). A total of 21 cases were performed prior to 2018. Overall OT for STC was 222.81 min (SD ± 14.54) compared to overall TPC OT 347.81 min (SD ± 34.35). Median length of stay was 5 days [25th and 75th percentiles 4, 6, respectively]. There was no 30-day mortality and only one return to operating room for mesenteric bleeding. There was a low risk of mortality associated with this technique.ConclusionsThe current study provides the largest cohort of patients assessed who have undergone multiquadrant robotic STC or TPC. The study provides a detailed description of the technique utilized at our institution. There was no associated 30-day mortality and a low risk of morbidity. The data suggest that the learning curve for improved operative time is between 15 and 20 cases.

BackgroundThe use of the surgical robot has increased annually since its introduction, especially in general surgery. Despite the tremendous increase in utilization, there are currently no validated curricula to train residents in robotic surgery, and the effects of robotic surgery on general surgery residency training are not well defined. In this study, we aim to explore the perceptions of resident and attending surgeons toward robotic surgery education in general surgery residency training.MethodsWe performed a qualitative thematic analysis of in-person, one-on-one, semi-structured interviews with general surgery residents and attending surgeons at a large academic health system. Convenient and purposeful sampling was performed in order to ensure diverse demographics, experiences, and opinions were represented. Data were analyzed continuously, and interviews were conducted until thematic saturation was reached, which occurred after 20 residents and seven attendings.ResultsAll interviewees agreed that dual consoles are necessary to maximize the teaching potential of the robotic platform, and the importance of simulation and simulators in robotic surgery education is paramount. However, further work to ensure proper access to simulation resources for residents is necessary. While most recognize that bedside-assist skills are essential, most think its educational value plateaus quickly. Lastly, residents believe that earlier exposure to robotic surgery is necessary and that almost every case has a portion that is level-appropriate for residents to perform on the robot.ConclusionsAs robotic surgery transitions from novelty to ubiquity, the importance of effective general surgery robotic surgery training during residency is paramount. Through in-depth interviews, this study provides examples of effective educational tools and techniques, highlights the importance of simulation, and explores opinions regarding the role of the resident in robotic surgery education. We hope the insights gained from this study can be used to develop and/or refine robotic surgery curricula.

BackgroundThe loss of tactile feedback in minimally invasive robotic surgery remains a major challenge to the expanding field. With visual cue compensation alone, tissue characterization via palpation proves to be immensely difficult. This work evaluates a bimodal vibrotactile system as a means of conveying applied forces to simulate haptic feedback in two sets of studies simulating an artificial palpation task using the da Vinci surgical robot.MethodsSubjects in the first study were tasked with localizing an embedded vessel in a soft tissue phantom using a single-sensor unit. In the second study, subjects localized tumor-like structures using a three-sensor array. In both sets of studies, subjects completed the task under three trial conditions: no feedback, normal force tactile feedback, and hybrid vibrotactile feedback. Recordings of correct localization, incorrect localization, and time-to-completion were used to evaluate performance outcomes.ResultsWith the addition of vibrotactile and pneumatic feedback, significant improvements in the percentage of correct localization attempts were detected (p = 0.0001 and p = 0.0459, respectively) during the first experiment with phantom vessels. Similarly, significant improvements in correct localization were found with the addition of vibrotactile (p = 2.57E-5) and pneumatic significance (p = 8.54E-5) were observed in the second experiment involving tumor phantoms.ConclusionsThis work demonstrates not only the superior benefits of a multi-modal feedback over traditional single-modality feedback, but also the effectiveness of vibration in providing haptic feedback to artificial palpation systems.

BACKGROUND:Laparoscopic sleeve gastrectomy has become the procedure of choice for the treatment of morbid obesity. Robotic sleeve gastrectomy is an alternative surgical option, but its utilization has been low. The aim of this study was to evaluate the contemporary outcomes of robotic sleeve gastrectomy (RSG) versus laparoscopic sleeve gastrectomy (LSG) using a national database from accredited bariatric centers. STUDY DESIGN:Using the 2015 Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) database, clinical data for patients who underwent RSG or LSG were examined. Emergent and revisional cases were excluded. A multivariate logistic regression model was utilized to compare the outcomes between RSG and LSG. RESULTS:A total of 75,079 patients underwent sleeve gastrectomy with 70,298 (93.6%) LSG and 4781 (6.4%) RSG. Preoperative sleep apnea and hypoalbumenia were significantly higher in the RSG group (P

BACKGROUND:Robotic total pancreatectomy (TP) represents a minimally invasive approach to a major intra-abdominal operation. Its utility, technique, and outcomes are evolving. METHODS:In this video, we describe a systematic approach to a robotic total pancreatectomy performed for multifocal intraductal papillary mucinous neoplasm (IPMN). Additionally, we reviewed the National Cancer Database (NCDB) to examine the outcomes of robotic TP compared to laparoscopic and open TP between 2010 and 2014. RESULTS:The patient is a 61-year-old female who was diagnosed with multifocal IPMN. A total of 6 robotic ports were placed and the da Vinci Xi robotic system was used with the patient supine. The approach entailed as follows: (1) Diagnostic laparoscopy; (2) Entry into the lesser sac; (3) Division of the short gastric vessels; (4) Exposure and dissection of the inferior pancreas border; (5) Dissection and transection of the splenic artery; (6) Mobilization of the pancreas tail/spleen; (7) Exposure of the splenic vein-superior mesenteric vein confluence; (8) Kocher maneuver; (9) Release of the ligament of Treitz and transection of the proximal jejunum; (10) Transection of the distal stomach; (11) Portal lymphadenectomy; (12) Dissection and transection of the gastroduodenal artery; (13) Superior mesenteric vein exposure/dissection of the uncinate process; (14) Hepaticojejunostomy; (15) Cholecystectomy; and (16) Gastrojejunostomy. NCDB database review of 73 patients who underwent robotic TP revealed similar rates of margin negative resections and retrieved lymph nodes between robotic, laparoscopic, and open TP, whereas robotic and laparoscopic TP were associated with shorter in-hospital stay and reduced mortality at 30 and 90 days compared to open TP. Overall median survival of pancreatic adenocarcinoma patients who underwent TP was similar between robotic, laparoscopic, and open approaches. CONCLUSION:Robotic total pancreatectomy with splenectomy offers a minimally invasive approach to a major abdominal operation and is feasible in a stepwise, reproducible technique. It is associated with improved postoperative outcomes and equivalent oncologic outcomes compared to open TP.

Background: The adoption of Robotic Pancreaticoduodenectomy (RPD) is increasing globally. Meanwhile, reduced-port RPD (RPRPD) remains uncommon, requiring robot-specific techniques not possible with laparoscopy. We introduce a unique RPRPD technique optimizing surgical field exposure., Methods: Our RPRPD utilizes a single-site plus-two ports technique, facilitated by a single-port platform through a 5-cm incision. The configuration of robotic arms (arm1, arm2, arm3, and arm4) were strategically designed for optimal procedural efficiency, with the arms2 and arm3, alongside the assistant trocar, mounted on the single-port platform, while the arms1 and arm4 were positioned laterally across the abdomen. Drainage was established via channels created at the arm1 and arm4 insertion sites. A "gooseneck traction" was principally employed with the robotic instrument to prop up the specimen rather than grasp, improving the surgical field's visibility and access. Clinical outcomes of patients who underwent RPRPD performed between August 2020 and September 2023 by a single surgeon across two centers in Taiwan and Japan were reviewed., Results: Fifty patients underwent RPRPD using the single-site plus-two ports technique. The gooseneck traction technique enabled goodsurgical field deployment and allowed for unrestricted movement of robotic arms with no collisions with the assistant instruments. The median operative time was 351 min (250-488 min), including 271 min (219-422 min) of console time and three minutes (2-10 min) of docking time. The median estimated blood loss was 80 mL (1-872 mL). All RPRPD procedures were successfully performed without the need for conversion to open surgery. Postoperative major morbidity (i.e., Clavien-Dindo grade ≥ IIIa) was observed in 6 (12%) patients and median postoperative hospital stay was 13 days., Conclusions: The single-site plus-two ports RPRPD with the gooseneck traction proves to be a safe, feasible option, facilitating surgical field visibility and robotic arm maneuverability., (© 2024. The Author(s).)

Background: As the population ages, more older adults are presenting for surgery. Age-related declines in physiological reserve and functional capacity can result in frailty and poor outcomes after surgery. Hence, optimizing perioperative care in older patients is imperative. Enhanced Recovery After Surgery (ERAS) pathways and Minimally Invasive Surgery (MIS) may influence surgical outcomes, but current use and impact on older adults patients is unknown. The aim of this study was to provide evidence-based recommendations on perioperative care of older adults undergoing major abdominal surgery., Methods: Expert consensus determined working definitions for key terms and metrics related to perioperative care. A systematic literature review and meta-analysis was performed using the PubMed, Embase, Cochrane Library, and Clinicaltrials.gov databases for 24 pre-defined key questions in the topic areas of prehabilitation, MIS, and ERAS in major abdominal surgery (colorectal, upper gastrointestinal (UGI), Hernia, and hepatopancreatic biliary (HPB)) to generate evidence-based recommendations following the GRADE methodology., Result: Older adults were defined as 65 years and older. Over 20,000 articles were initially retrieved from search parameters. Evidence synthesis was performed across the three topic areas from 172 studies, with meta-analyses conducted for MIS and ERAS topics. The use of MIS and ERAS was recommended for older adult patients particularly when undergoing colorectal surgery. Expert opinion recommended prehabilitation, cessation of smoking and alcohol, and correction of anemia in all colorectal, UGI, Hernia, and HPB procedures in older adults. All recommendations were conditional, with low to very low certainty of evidence, with the exception of ERAS program in colorectal surgery., Conclusions: MIS and ERAS are recommended in older adults undergoing major abdominal surgery, with evidence supporting use in colorectal surgery. Though expert opinion supported prehabilitation, there is insufficient evidence supporting use. This work has identified evidence gaps for further studies to optimize older adults undergoing major abdominal surgery., (© 2024. The Author(s).)

Background: The optimal approach for the safe implementation and education of robotic pancreaticoduodenectomy (RPD) remains unclear. Prolonged operation time may cause surgeon fatigue and result in perioperative complications. To solve this issue, our department adopted task division by the console surgeon turnover between resection and reconstruction in 2022., Methods: This study retrospectively investigated consecutive patients who underwent RPD from November 2009 (initial introduction of RPD) to December 2023. The analysis excluded patients who underwent concomitant resection of other organs. The cases performed by a single console surgeon (single approach) were compared with those performed by two or more console surgeons (multiple approach)., Results: This study analyzed 85 consecutive RPD cases, including 51 with the single approach and 34 with the multiple approach. The operation time was significantly shorter (832 vs. 618 min, p < 0.001), and the postoperative major complication was less frequent (45% vs. 12%, p = 0.003) in the multiple approach group, although less experienced surgeons performed the multiple approach (number of RPD experiences: 19 cases vs. 5 cases, p < 0.001). The console surgeon turnover between the resection and reconstruction resulted in a safe pancreatojejunostomy performed by the less experienced surgeon (number of pancreatic reconstruction experiences: 6.5 vs. 14 cases, p = 0.010). Surgeons who started RPD with a multiple approach observed a reduction in surgical time and a lower incidence of complications earlier than those who started with a single approach., Conclusion: Task division during the early introduction phase of RPD using the multiple approach demonstrated potential contributions to improved surgical outcomes and enhanced educational benefits., (© 2024. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Background: Associations between procedure volumes and outcomes can inform minimum volume standards and the regionalization of health services. Robot-assisted surgery continues to expand globally; however, data are limited regarding which hospitals should be using the technology., Study Design: Using administrative health data for all residents of Ontario, Canada, this retrospective cohort study included adult patients who underwent a robot-assisted radical prostatectomy (RARP), total robotic hysterectomy (TRH), robot-assisted partial nephrectomy (RAPN), or robotic portal lobectomy using 4 arms (RPL-4) between January 2010 and September 2021. Associations between yearly hospital volumes and 90-day major complications were evaluated using multivariable logistic regression models adjusted for patient characteristics and clustering at the level of the hospital., Results: A total of 10,879 patients were included, with 7567, 1776, 724, and 812 undergoing a RARP, TRH, RAPN, and RPL-4, respectively. Yearly hospital volume was not associated with 90-day complications for any procedure. Doubling of yearly volume was associated with a 17-min decrease in operative time for RARP (95% confidence interval [CI] - 23 to - 10), 8-min decrease for RAPN (95% CI - 14 to - 2), 24-min decrease for RPL-4 (95% CI - 29 to - 19), and no significant change for TRH (- 7 min; 95% CI - 17 to 3)., Conclusion: The risk of 90-day major complications does not appear to be higher in low volume hospitals; however, they may not be as efficient with operating room utilization. Careful case selection may have contributed to the lack of an observed association between volumes and complications., (© 2024. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

BackgroundThe principal objective of the experiment was to analyze the effects of the clutch operation of robotic surgical systems on the performance of the operator. The relative coordinate system introduced by the clutch operation can introduce a visual-perceptual mismatch which can potentially have negative impact on a surgeon's performance. We also assess the impact of the introduction of additional tactile sensory information on reducing the impact of visual-perceptual mismatch on the performance of the operator.MethodsWe asked 45 novice subjects to complete peg transfers using the da Vinci IS 1200 system with grasper-mounted, normal force sensors. The task involves picking up a peg with one of the robotic arms, passing it to the other arm, and then placing it on the opposite side of the view. Subjects were divided into three groups: aligned group (no mismatch), the misaligned group (10 cm z axis mismatch), and the haptics-misaligned group (haptic feedback and z axis mismatch). Each subject performed the task five times, during which the grip force, time of completion, and number of faults were recorded.ResultsCompared to the subjects that performed the tasks using a properly aligned controller/arm configuration, subjects with a single-axis misalignment showed significantly more peg drops (p = 0.011) and longer time to completion (p

IntroductionMinimally invasive adrenalectomy may be associated with reduction in postoperative pain, morbidity, and length of stay and, as a result, has become a preferred approach for many adrenal tumors. Left-sided adrenal tumors, however, are particularly challenging to address in the morbidly obese patient due to difficulties in maintaining exposure and dissection. The robotic platform offers instruments with greater degrees of freedom that aid in retraction and dissection, especially of the adrenal vein, but fixed patient positioning and the large distance needed between patient ports to avoid arm collisions can be restrictive in patients with a large amount of retroperitoneal fat and small working space.Methods/resultsWe demonstrate robotic left adrenalectomy (RLA) in a consecutive series of patients with a mean weight of 99 kg and mean BMI of 36. Techniques to safely and efficiently perform RLA in obese patients are stepwise demonstrated, including (1) Patient positioning, (2) Management of the pannus, (3) Customized port placement, (4) Medial retraction of the pancreas, (5) Finding the left adrenal vein, and (6) Management of bleeding. Intraoperative videos from multiple patients also show surgical pitfalls, examples of poor port placement, arm collisions, alternative approaches to the vein, and techniques to control unexpected bleeding. All patients in the series underwent successful RLA with negative margins, no major intra- or postoperative complications, and discharge on POD 1-2.ConclusionThough poor exposure due to patient body habitus is a relative contraindication, even large left-sided adrenal tumors can be safely approached robotically while adhering to oncologic principles, as is demonstrated in this video.

IntroductionThe aims of this study were to evaluate (1) grasping forces with the application of a tactile feedback system in vivo and (2) the incidence of tissue damage incurred during robotic tissue manipulation. Robotic-assisted minimally invasive surgery has been shown to be beneficial in a variety of surgical specialties, particularly radical prostatectomy. This innovative surgical tool offers advantages over traditional laparoscopic techniques, such as improved wrist-like maneuverability, stereoscopic video displays, and scaling of surgical gestures to increase precision. A widely cited disadvantage associated with robotic systems is the absence of tactile feedback.Methods and procedureNineteen subjects were categorized into two groups: 5 experts (six or more robotic cases) and 14 novices (five cases or less). The subjects used the da Vinci with integrated tactile feedback to run porcine bowel in the following conditions: (T1: deactivated tactile feedback; T2: activated tactile feedback; and T3: deactivated tactile feedback). The grasping force, incidence of tissue damage, and the correlation of grasping force and tissue damage were analyzed. Tissue damage was evaluated both grossly and histologically by a pathologist blinded to the sample.ResultsTactile feedback resulted in significantly decreased grasping forces for both experts and novices (P  0.05 in all subjects).ConclusionThe in vivo application of integrated tactile feedback in the robotic system demonstrates significantly reduced grasping forces, resulting in significantly less tissue damage. This tactile feedback system may improve surgical outcomes and broaden the use of robotic-assisted minimally invasive surgery.

BackgroundThe utilization of minimally invasive surgery is increasing in colorectal surgery. We sought to compare the outcomes of patients who underwent elective open, laparoscopic, and robotic total abdominal colectomy.MethodsThe NIS database was used to examine the clinical data of patients who underwent an elective total colectomy procedure during 2009-2012. Multivariate regression analysis was performed to compare the three surgical approaches.ResultsWe sampled a total of 26,721 patients who underwent elective total colectomy. Of these, 16,780 (62.8 %) had an open operation, while 9934 (37.2 %) had a minimally invasive approach (9614 laparoscopic surgery, and 326 robotic surgery). The most common indication for an operation was ulcerative colitis (31 %). Patients who underwent open surgery had significantly higher mortality and morbidity compared to laparoscopic (AOR 2.48, 1.30, P

Background: Currently, widely used robotic surgical systems do not provide force feedback. This study aimed to evaluate the impact and benefits of a force feedback function on the suturing procedure., Methods: Twenty surgeons were recruited and divided into young (Y-group, n = 11) and senior (S-group, n = 9) groups, based on their years of surgical experience. The effect of the force feedback function on suturing quality was evaluated using an objective assessment system (A-LAP mini, Kyoto Kagaku Co., Ltd., Kyoto, Japan). Each participant completed the suturing task on intestinal model sheets with the robotic contact force feedback on and off. The task accomplishment time (s), maximal force (Newton, N) applied to the robotic forceps, and quality of suturing (assessed by A-LAP mini) were recorded as performance parameters., Results: In total, the maximal force applied to the robotic forceps was significantly decreased with the robotic force feedback switched on (median [interquartile range]: 2.8 N (2.3-3.2)) as compared with when the feedback was switched off (3.4 N (2.7-4.0), P < 0.001). The contact force feedback function did not affect the objectively assessed suturing score (18 points (17.7-19.0) versus 18 points (17.0-19.0), P = 0.421). The contact force feedback function slightly shortened the task accomplishment time in the Y-group (552.5 s (466.5-832) versus 605.5 s (476.2-689.7), P = 0.851) but not in the S-group (566 s (440.2-703.5) versus 470.5 s (419.7-560.2), P = 0.164)., Conclusions: With the contact force feedback function, the suturing task was completed with a smaller maximal force, while maintaining the quality of suturing. Because the benefits are more apparent in young surgeons, robots with the contact force feedback function will facilitate the educational process in novice surgeons., (© 2023. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Background: Robot-assisted surgery has been rapidly adopted. It is important to define the learning curve to inform credentialling requirements, training programs, identify fast and slow learners, and protect patients. This study aimed to characterize the hospital learning curve for common robot-assisted procedures., Study Design: This cohort study, using administrative health data for Ontario, Canada, included adult patients who underwent a robot-assisted radical prostatectomy (RARP), total robotic hysterectomy (TRH), robot-assisted partial nephrectomy (RAPN), or robotic portal lobectomy using four arms (RPL-4) between 2010 and 2021. The association between cumulative hospital volume of a robot-assisted procedure and major complications was evaluated using multivariable logistic models adjusted for patient characteristics and clustering at the hospital level., Results: A total of 6814 patients were included, with 5230, 543, 465, and 576 patients in the RARP, TRH, RAPN, and RPL-4 cohorts, respectively. There was no association between cumulative hospital volume and major complications. Visual inspection of learning curves demonstrated a transient worsening of outcomes followed by subsequent improvements with experience. Operative time decreased for all procedures with increasing volume and reached plateaus after approximately 300 RARPs, 75 TRHs, and 150 RPL-4s. The odds of a prolonged length of stay decreased with increasing volume for patients undergoing a RARP (OR 0.87; 95% CI 0.82-0.92) or RPL-4 (OR 0.77; 95% CI 0.68-0.87)., Conclusion: Hospitals may adopt robot-assisted surgery without significantly increasing the risk of major complications for patients early in the learning curve and with an expectation of increasing efficiency., (© 2023. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Background: Although the da Vinci™ Surgical System is the most predominantly used surgical robot worldwide, other surgical robots are being developed. The Japanese surgical robot hinotori™ Surgical Robot System was launched and approved for clinical use in Japan in November 2022. We performed the first robotic gastrectomy for gastric cancer using hinotori in the world. Here, we report our initial experience and evaluation of the feasibility and safety of robotic gastrectomy for gastric cancer using hinotori., Methods: A single-institution retrospective study was conducted. Between November 2022 and October 2023, 24 patients with gastric cancer underwent robotic gastrectomy with hinotori. Five ports, including one for an assistant, were placed in the upper abdomen, and gastric resection with standard lymphadenectomy and intracorporeal reconstruction were performed. The primary endpoint was the postoperative complication rate within 30 days after surgery. The secondary outcomes were surgical outcomes, including intraoperative adverse events, operative time, blood loss, and the number of dissected nodes., Results: Of the 24 patients, 16 (66.7%) were male. The median age and body mass index were 73.5 years and 22.9 kg/m 2 , respectively. Twenty-three patients (95.8%) had tumors in the middle to lower stomach. Sixteen (66.7%) and seven (29.2%) patients had clinical stage I and II diseases, respectively. Twenty-three (95.8%) patients underwent distal gastrectomy. No patient had postoperative complications of Clavien-Dindo classification IIIa or higher, whereas two (8.3%) had the grade II complications (enteritis and pneumonia). No intraoperative adverse events, including conversion to other approaches, were observed. All patients received R0 resection. The median operative and console times were 400 and 305 min, respectively. The median blood loss was 14.5 mL, and the number of lymph nodes dissected was 51.5., Conclusions: This study found that robotic gastrectomy with standard lymphadenectomy for gastric cancer using hinotori can be safely performed., (© 2024. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Background: Robotic distal pancreatectomy has increasingly been accepted as it has overcome some of the limitations of open distal pancreatectomy, whilst the outcomes following robotic radical antegrade modular pancreatosplenectomy (RAMPS) in patients with pancreatic ductal adenocarcinoma (PDAC) are still uncertain. This study aimed to evaluate the short and long-term outcomes of robotic RAMPS and open RAMPS for PDAC., Methods: The patients who underwent robotic RAMPS and open RAMPS for PDAC at our clinical centre between January 2017 and December 2021 were reviewed. After a propensity score matching (PSM) at a 1:1 ratio, the perioperative and pathological outcomes in the both groups were reviewed. Univariable and multivariable Cox regression analyses were used to identify independent prognosis factors for overall survival (OS) and recurrence-free survival (RFS) of these patients., Results: 318 cases were recorded in robotic and open groups. The robotic group showed advantages in operative time [205.00 (166.00, 240.00) min vs 235 (184.75, 270.00) min, P = 0.002], estimated blood loss [100 (50, 100) ml vs 300 (100, 400) ml, P < 0.001], delayed gastric emptying [0 vs 5.03%, P = 0.007] and postoperative hospital stay [7.00 (5.00, 10.00) days vs 11.00 (8.00, 14.00) days, P < 0.001]. There were no significant differences in rate of severe postoperative complications between the robotic group and the open group. Multivariable analysis showed that carbohydrate antigen 19-9, estimated blood loss, N stage, tumour differentiation, chemotherapy and vascular invasion were independent risk factors for OS and RFS of these patients., Conclusions: Robotic RAMPS was safe and had some advantages over open RAMPS for PDAC. There were no significantly differences in oncological outcomes and long-term survival rates between the robotic and open groups. Robotic RAMPS expanded the indications for minimally invasive surgeries for PDAC to a certain extent., (© 2023. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Background: Achalasia is a rare disorder of the esophagus characterized by motor dysfunction in the esophagus and relaxation failure of the lower esophageal sphincter (LES). Currently, surgical myotomy procedures are considered the standard of care. Robotic Heller's myotomy (RHM) with fundoplication has been gaining popularity due to documented advantages in the precision of myotomy as well as avoiding the potential reflux following per-oral endoscopic myotomy (POEM). To the best of our knowledge, RHM has thus far has been performed exclusively by the da Vinci surgical system. The new Hugo RAS™ system offers a unique modular design and an open console which offers better maneuverability and docking options. In this study, we present the first worldwide series of patients undergoing RHM using the new Hugo RAS™ platform. Our objective is to propose optimal operating configuration and setup to fully harness the advantages of the unique modular design of this system., Methods: Ten consecutive achalasia patients underwent Robotic Heller's myotomy (RHM) with the Hugo RAS™ system. We prospectively collected patient data, including demographics, comorbidities, ASA class, Eckardt scores, pre-operative manometric data, and EndoFlip parameters. Additionally, we recorded the docking and total operative times., Results: Between December 2022 and August 2023, 10 patients underwent RHM with the Hugo™ RAS system. Patients had a median age of 42.5 years, 60% were female, and mean BMI was 23.2. Fifty percent had achalasia type 2 and 50% type 1. The median pre-operative integrated relaxation pressure (IRP) was 24.9. Median docking time was 10 min and overall operative time was 129.5 min. All patients, except one with acute coronary syndrome, had an uneventful peri-operative course and were discharged on post-operative day 2., Conclusion: The Hugo™ RAS system is well designed for robotic Heller myotomy. The operative and clinical results are similar to the currently used robotic system; however, the modular design of the system has some differences. These translate to better docking angles and maneuverability as well as console surgeon's ergonomics. Further experience is needed to explore the advantages of the system's modular design and function., (© 2023. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Background: Digital surgery is a new paradigm within the surgical innovation space that is rapidly advancing and encompasses multiple areas., Methods: This white paper from the SAGES Digital Surgery Working Group outlines the scope of digital surgery, defines key terms, and analyzes the challenges and opportunities surrounding this disruptive technology., Results: In its simplest form, digital surgery inserts a computer interface between surgeon and patient. We divide the digital surgery space into the following elements: advanced visualization, enhanced instrumentation, data capture, data analytics with artificial intelligence/machine learning, connectivity via telepresence, and robotic surgical platforms. We will define each area, describe specific terminology, review current advances as well as discuss limitations and opportunities for future growth., Conclusion: Digital Surgery will continue to evolve and has great potential to bring value to all levels of the healthcare system. The surgical community has an essential role in understanding, developing, and guiding this emerging field., (© 2024. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Background: The rapid adoption of robotics within minimally invasive surgical specialties has also seen an explosion of new technology including multi- and single port, natural orifice transluminal endoscopic surgery (NOTES), endoluminal and "on-demand" platforms. This review aims to evaluate the validation status of current and emerging MIS robotic platforms, using the IDEAL Framework., Methods: A scoping review exploring robotic minimally invasive surgical devices, technology and systems in use or being developed was performed, including general surgery, gynaecology, urology and cardiothoracics. Systems operating purely outside the abdomen or thorax and endoluminal or natural orifice platforms were excluded. PubMed, Google Scholar, journal reports and information from the public domain were collected. Each company was approached via email for a virtual interview to discover more about the systems and to quality check data. The IDEAL Framework is an internationally accepted tool to evaluate novel surgical technology, consisting of four stages: idea, development/exploration, assessment, and surveillance. An IDEAL stage, synonymous with validation status in this review, was assigned by reviewing the published literature., Results: 21 companies with 23 different robotic platforms were identified for data collection, 13 with national and/or international regulatory approval. Of the 17 multiport systems, 1 is fully evaluated at stage 4, 2 are stage 3, 6 stage 2b, 2 at stage 2a, 2 stage 1, and 4 at the pre-IDEAL stage 0. Of the 6 single-port systems none have been fully evaluated with 1 at stage 3, 3 at stage 1 and 2 at stage 0., Conclusions: The majority of existing robotic platforms are currently at the preclinical to developmental and exploratory stage of evaluation. Using the IDEAL framework will ensure that emerging robotic platforms are fully evaluated with long-term data, to inform the surgical workforce and ensure patient safety., (© 2023. The Author(s).)

Background: 3D computed tomography (CT) has been seldom used for the evaluation of hiatal hernias (HH) in surgical patients. This study aims to describe the 3D CT findings in candidates for laparoscopic or robotic antireflux surgery or HH repair and compare them with other tests., Methods: Thirty patients with HH and/or gastroesophageal reflux disease (GERD) who were candidates for surgical treatment and underwent high-resolution CT were recruited. The variables studied were distance from the esophagogastric junction (EGJ) to the hiatus; total gastric volume and herniated gastric volume, percentage of herniated volume in relation to the total gastric volume; diameters and area of the esophageal hiatus., Results: HH was diagnosed with CT in 21 (70%) patients. There was no correlation between the distance EGJ-hiatus and the herniated gastric volume. There was a statistically significant correlation between the distance from the EGJ to the hiatus and the area of the esophageal hiatus of the diaphragm. There was correlation between tomographic and endoscopic findings for the presence and size of HH. HH was diagnosed with manometry in 9 (50%) patients. There was no correlation between tomographic and manometric findings for the diagnosis of HH and between hiatal area and lower esophageal sphincter basal pressure. There was no correlation between any parameter and DeMeester score., Conclusions: The anatomy of HH and the hiatus can be well defined by 3D CT. The EGJ-hiatus distance may be equally measured by 3D CT or upper digestive endoscopy. DeMeester score did not correlate with any anatomical parameter., (© 2023. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Objective: How different surgical procedures, including the robotic-assisted liver resection (RLR) and laparoscopic liver resection (LLR), can affect the prognosis of patients with liver malignancies is unclear. Thus, in this study, we compared the effects of RLR and LLR on the surgical and oncological outcomes in patients with liver malignancies through propensity score-matched cohort studies., Methods: The PubMed, Embase, and Cochrane databases were searched using Medical Subject Headings terms and keywords from inception until May 31, 2023. The quality of the included studies was assessed using the Newcastle-Ottawa quality assessment scale. The mean difference with 95% confidence interval (95% CI) was used for analysis of continuous variables; the risk ratio with 95% CI was used for dichotomous variables; and the hazard ratio with 95% CI was used for survival-related variables. Meta-analysis was performed using a random-effects model., Results: Five high-quality cohort studies with 986 patients were included (370 and 616 cases for RLR and LLR, respectively). In terms of surgical outcomes, there were no significant differences in the operation time, conversion rate to open surgery, overall complication rate, major complication rate, and length of hospital stay between the RLR and LLR groups. In terms of oncological outcomes, there were no significant differences in the 5-year overall survival and disease-free survival between the two groups., Conclusion: Surgical and oncological outcomes are comparable between RLR and LLR on patients with liver malignancies. Therefore, the benefits of applying RLR in patients with liver malignancies need to be further explored., (© 2023. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Background: Surgical tele-mentoring leverages technology by projecting surgical expertise to improve access to care and patient outcomes. We postulate that tele-mentoring will improve surgeon satisfaction, procedural competence, the timeliness of operative intervention, surgical procedure efficiency, and key intra-operative decision-making. As a first step, we performed a pilot study utilizing a proof-of-concept tele-mentoring process during robotic-assisted surgery to determine the effects on the perceptions of all members of the surgical team., Methods: An IRB-approved prospective feasibility study to determine the safety and efficacy of remote surgical consultation to local surgeons utilizing robotic surgery technology in the fields of general, urology, gynecology and thoracic surgery was performed. Surgical teams were provided a pre-operative face-to-face orientation. During the operation, the mentoring surgeon was located at the same institution in a separate tele-mentoring room. An evaluation was completed pre- and post-operatively by the operative team members and mentor., Results: Fifteen operative cases were enrolled including seven general surgery, four urology, one gynecology and three thoracic surgery operations. Surveys were collected from 67 paired survey respondents and 15 non-paired mentor respondents. Participation in the operation had a positive effect on participant responses regarding all questions surveyed (p < 0.05) indicating value to tele-mentoring integration. Connectivity remained uninterrupted with clear delivery of audio and visual components and no perceived latency. Participant perception of leadership/administrative support was varied., Conclusions: Surgical tele-mentoring is safe and efficacious in providing remote surgical consultation to local surgeons utilizing robotic surgery technology in a military institution. Operative teams overwhelmingly perceived this capability as beneficial with reliable audio-visual connectivity demonstrated between the main operative room and the Virtual Medical Center. Further study is needed to develop surgical tele-mentoring to improve patient care without geographic limitations during times of peace, war and pandemic outbreaks., (© 2023. This is a U.S. Government work and not under copyright protection in the US; foreign copyright protection may apply.)

Background: Robotic surgery has experienced exponential growth in the past decade. Few studies have evaluated the impact of robotics within minimally invasive surgery (MIS) fellowship training programs. The purpose of our study was to examine and characterize recent trends in robotic surgery within MIS fellowship training programs., Methods: De-identified case log data from the Fellowship Council from 2010 to 2021 were evaluated. Percentage of operations performed with robot assistance over time was assessed and compared to the laparoscopic and open experience. Case logs were further stratified by operative category (e.g., bariatric, hernia, foregut), and robotic experience over time was evaluated for each category. Programs were stratified by percent robot use and the experience over time within each quartile was evaluated., Results: MIS fellowship training programs with a robotic platform increased from 45.1% (51/113) to 90.4% (123/136) over the study period. The percentage of robotic cases increased from 2.0% (1127/56,033) to 23.2% (16,139/69,496) while laparoscopic cases decreased from 80.2% (44,954/56,033) to 65.3% (45,356/69,496). Hernia and colorectal case categories had the largest increase in robot usage [hernia: 0.7% (62/8614) to 38.4% (4661/12,135); colorectal 4.2% (116/2747) to 31.8% (666/2094)]. When stratified by percentage of robot utilization, current (2020-2021) programs in the > 95th percentile performed 21.8% (3523/16,139) of robotic operations and programs in the > 50th percentile performed 90.0% (14,533/16,139) of all robotic cases. The median number of robotic cases performed per MIS fellow significantly increased from 2010 to 2021 [0 (0-6) to 72.5 (17.8-171.5), p < 0.01]., Conclusions: Robotic use in MIS fellowship training programs has grown substantially in the past decade, but the laparoscopic and open experience remains robust. There remains an imbalance with the top 50% of busiest robotic programs performing over 90% of robot trainee cases. The experience in MIS programs varies widely and trainees should examine program case logs closely to confirm parallel interests., (© 2023. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Background: The safe and effective performance of a robotic roux-en-y gastric bypass (RRNY) requires the application of a complex body of knowledge and skills. This qualitative study aims to: (1) define the tasks, subtasks, decision points, and pitfalls in a RRNY; (2) create a framework upon which training and objective evaluation of a RRNY can be based., Methods: Hierarchical and cognitive task analyses for a RRNY were performed using semi-structured interviews of expert bariatric surgeons to describe the thoughts and behaviors that exemplify optimal performance. Verbal data was recorded, transcribed verbatim, supplemented with literary and video resources, coded, and thematically analyzed., Results: A conceptual framework was synthesized based on three book chapters, three articles, eight online videos, nine field observations, and interviews of four subject matter experts (SME). At the time of the interview, SME had practiced a median of 12.5 years and had completed a median of 424 RRNY cases. They estimated the number of RRNY to achieve competence and expertise were 25 cases and 237.5 cases, respectively. After four rounds of inductive analysis, 83 subtasks, 75 potential errors, 60 technical tips, and 15 decision points were identified and categorized into eight major procedural steps (pre-procedure preparation, abdominal entry & port placement, gastric pouch creation, omega loop creation, gastrojejunal anastomosis, jejunojejunal anastomosis, closure of mesenteric defects, leak test & port closure). Nine cognitive behaviors were elucidated (respect for patient-specific factors, tactical modification, adherence to core surgical principles, task completion, judicious technique & instrument selection, visuospatial awareness, team-based communication, anticipation & forward planning, finessed tissue handling)., Conclusion: This study defines the key elements that formed the basis of a conceptual framework used by expert bariatric surgeons to perform the RRNY safely and effectively. This framework has the potential to serve as foundational tool for training novices., (© 2023. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Background: We compared surgeons' workload, physical discomfort, and neuromusculoskeletal disorders (NMSDs) across four surgical modalities: endoscopic, laparoscopic, open, and robot-assisted (da Vinci Surgical Systems)., Methods: An electronic survey was sent to the surgeons across an academic hospital system. The survey consisted of 47 questions including: (I) Demographics and anthropometrics; (II) The percentage of the procedural time that the surgeon spent on performing each surgical modality; (III) Physical and mental demand and physical discomfort; (IV) Neuromusculoskeletal symptoms including body part pain and NMSDs., Results: Seventy-nine out of 245 surgeons completed the survey (32.2%) and 65 surgeons (82.2%) had a dominant surgical modality: 10 endoscopic, 15 laparoscopic, 26 open, and 14 robotic surgeons. Physical demand was the highest for open surgery and the lowest for endoscopic and robotic surgeries, (all p < 0.05). Open and robotic surgeries required the highest levels of mental workload followed by laparoscopic and endoscopic surgeries, respectively (all p < 0.05 except for the difference between robotic and laparoscopic that was not significant). Body part discomfort or pain (immediately after surgery) were lower in the shoulder for robotic surgeons compared to laparoscopic and open surgeons and in left fingers for robotic surgeons compared to endoscopic surgeons (all p < 0.05). The prevalence of NMSD was significantly lower in robotic surgeons (7%) compared to the other surgical modalities (between 60 and 67%) (all p < 0.05)., Conclusions: The distribution of NMSDs, workload, and physical discomfort varied significantly based on preferred surgical approach. Although robotic surgeons had fewer overall complaints, improvement in ergonomics of surgery are still warranted., (© 2023. The Author(s).)

Introduction: This review aims to describe the surgical options available for treatment of diastasis recti in postpartum women, as well as compare the effectiveness of these treatment options. Historically, diastasis recti has been repaired through open procedures, such as abdominoplasty. More recently, studies have explored other methods for the treatment of diastasis recti, including various minimally invasive surgical options., Methods: Twelve studies ranging from 2015 to 2022 were included in this analysis. Studies were identified using PubMed, EMBASE, and Cochrane Library. Studies that met the inclusion criteria were analyzed descriptively. Statistical comparison of surgical outcomes between studies was performed using Fisher's Exact Test in SPSS., Results: Minimally invasive approaches were categorized as laparoscopic preaponeurotic approaches, robotic approaches, and enhanced-view/extended totally extraperitoneal (eTEP) approaches. These techniques were compared to two open approaches: abdominoplasty and miniabdominoplasty. There were no significant differences in the rate of seromas, surgical site infections/complications, or hematomas between abdominoplasty and minimally invasive surgical techniques (p > 0.05). Among the minimally invasive techniques, no significant differences in readmission rates were reported (p > 0.05). Additionally, no significant differences in recurrence rates were seen following minimally invasive or abdominoplasty repairs, except for the increased recurrence rates seen with the r-TARRD robotic technique (p < 0.05)., Conclusion: Although current data on minimally invasive approaches is limited, our review reveals that both open and minimally invasive approaches are viable options for diastasis recti repair in postpartum women. Identifying the optimal approach for diastasis recti repair should rely on the patient's desired treatment outcome. If the patient indicates a desire for the removal of excess abdominal subcutaneous tissue, abdominoplasty may be a better surgical approach. Alternatively, if the patient puts a greater emphasis on shorter recovery time and smaller surgical incisions/scars, minimally invasive approaches may be a better surgical option., (© 2023. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Introduction: Surgery remains the cornerstone treatment for gastric cancer. Previous studies have reported better lymphadenectomy with minimally invasive approaches. There is a paucity of data comparing robotic and laparoscopic gastrectomy in the US. Herein, we examined whether oncological adequacy differs between laparoscopic and robotic approaches., Methods: The National Cancer Database was utilized to identify patients who underwent gastrectomy for adenocarcinoma between 2010 and 2019. A propensity score-matching analysis between robotic gastrectomy (RG) versus laparoscopic gastrectomy (LG) was performed. The primary outcomes were lymphadenectomy ≥ 16 nodes and surgical margins., Results: A total of 11,173 patients underwent minimally invasive surgery for gastric adenocarcinoma between 2010 and 2019. Of those 8320 underwent LG and 2853 RG. Comparing the unmatched cohorts, RG was associated with a higher rate of adequate lymphadenectomy (63.5% vs 57.1%, p < .0.0001), higher rate of negative margins (93.8% vs 91.9%, p < 0.001), lower rate of prolonged length of stay (26.0% vs 29.6%, p < .0.001), lower 90-day mortality (3.7% vs 5.0%, p < 0.0001), and a better 5-year overall survival (OS) (56% vs 54%, p = 0.03). A propensity score-matching cohort with a 1:1 ratio was created utilizing the variables associated with lymphadenectomy ≥ 16 nodes. The matched analysis revealed that the rate of adequate lymphadenectomy was significantly higher for RG compared to LG, 63.5% vs 60.4% (p = 0.01), respectively. There was no longer a significant difference between RG and LG regarding the rate of negative margins, prolonged length of stay, 90-day mortality, rate of receipt of postoperative chemotherapy, and OS., Conclusions: This propensity score-matching analysis with a large US cohort shows that RG was associated with a higher rate of adequate lymphadenectomy compared to LR. RG and LG had a similar rate of negative margins, prolonged length of stay, receipt of postoperative chemotherapy, 90-day mortality, and OS, suggesting that RG is a comparable surgical approach, if not superior to LG., (© 2023. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Background: Gastroesophageal reflux disease requiring an operative solution is common. Minimally invasive surgery to generate an anti-reflux barrier at the distal esophagus following the principle of the "floppy Nissen" technique has become the gold standard. Advanced robotic-assisted systems may deliver more consisted outcomes., Methods: This registry study analyzed safety and efficacy of the Senhance® surgical system in the surgical treatment of reflux disease and procedural proficiency. Data from 237 consecutive patients operated in a single center were evaluated. Historic standard laparoscopies from the same center were analyzed to compare robotic surgery learning curve effects., Results: Using the Senhance® Surgical System, during the first 50 patients there was a significant decrease in surgery time which was maintained over the duration of study, pointing to the surgical staff's system-specific learning. After this phase, procedural times were comparable between the robotic-assisted and traditional laparoscopic surgery. The effect of learning was greater than for standard laparoscopy. For 237 patients, there were four conversions to laparoscopic surgery. Two serious adverse events were recorded, both cardiac in nature and not related to the use of the robot., Conclusions: Robotic fundoplication was swiftly implemented in a non-university hospital with 65 surgical beds. The operating time was no longer than in standard laparoscopy, the procedure was more standardized than open or laparoscopic surgery and hospitalization times may have been sustainably shortened. The autonomy at the system's digital platform (cockpit) to conduct robotic fundoplications is a big step forward in surgery., (© 2023. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Background: Systematic lymph node dissection in patients with gastric cancer could be sufficiently and reproducibly achieved along the outermost layer of the autonomic nerves and similar concept has been extensively used for robotic esophagectomy (RE) since 2018. This study aimed to determine the surgical and oncological safety of RE using the outermost layer-oriented approach for esophageal cancer (EC)., Methods: Sixty-six patients who underwent RE with total mediastinal lymphadenectomy for primary EC between April 2018 and December 2021 were retrospectively reviewed. All underwent the outermost layer-oriented approach with intraoperative nerve monitoring (IONM). Postoperative complications within 30 days were analyzed., Results: Among the patients, 51 (77.3%) were male. The median age was 64 years, and the body mass index was 21.8 kg/m 2 . Furthermore, 58 (87.9%) patients had squamous cell carcinoma and eight (12.1%) patients had adenocarcinoma. Clinical stages I, II, and III were seen in 23 (34.8%), 23 (34.8%), and 16 (24.2%) patients, respectively. Thirty-four (51.5%) patients received preoperative treatment. No patient shifted to conventional thoracoscopic or open procedure intraoperatively. The median operative time was 716 min with 119 mL of blood loss. Additionally, 64 (97%) patients underwent R0 resection. The morbidity rates based on Clavien-Dindo grades ≥ II and ≥ IIIa were 30.3% and 10.6%, respectively, within 30 postoperative days. None died within 90 days postoperatively. Three (4.5%) patients exhibited recurrent laryngeal nerve (RLN) palsy (CD grade ≥ II). The sensitivity and specificity of IONM for RLN palsy were 50% and 98.3% at the right RLN and 33.3% and 98.0% at the left RLN, respectively., Conclusion: RE with the outermost layer-oriented approach can provide safe short-term outcomes., (© 2023. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Objective: This study explored the use of electroencephalogram (EEG) and eye gaze features, experience-related features, and machine learning to evaluate performance and learning rates in fundamentals of laparoscopic surgery (FLS) and robotic-assisted surgery (RAS)., Methods: EEG and eye-tracking data were collected from 25 participants performing three FLS and 22 participants performing two RAS tasks. Generalized linear mixed models, using L1-penalized estimation, were developed to objectify performance evaluation using EEG and eye gaze features, and linear models were developed to objectify learning rate evaluation using these features and performance scores at the first attempt. Experience metrics were added to evaluate their role in learning robotic surgery. The differences in performance across experience levels were tested using analysis of variance., Results: EEG and eye gaze features and experience-related features were important for evaluating performance in FLS and RAS tasks with reasonable results. Residents outperformed faculty in FLS peg transfer (p value = 0.04), while faculty and residents both excelled over pre-medical students in the FLS pattern cut (p value = 0.01 and p value < 0.001, respectively). Fellows outperformed pre-medical students in FLS suturing (p value = 0.01). In RAS tasks, both faculty and fellows surpassed pre-medical students (p values for the RAS pattern cut were 0.001 for faculty and 0.003 for fellows, while for RAS tissue dissection, the p value was less than 0.001 for both groups), with residents also showing superior skills in tissue dissection (p value  = 0.03)., Conclusion: Findings could be used to develop training interventions for improving surgical skills and have implications for understanding motor learning and designing interventions to enhance learning outcomes., (© 2023. The Author(s).)

Background: Robotics has been used safely and successfully in a variety of adult surgeries and is gradually gaining ground in pediatrics. While the benefits of robotic-assisted surgery in disease treatment are well recognized, its high cost has led to questions. To investigate whether robotic-assisted laparoscopic surgery (RALS) is cost-effective compared to conventional laparoscopic surgery (LS) in pediatric surgery, we attempted to construct a model to perform an analysis of these two surgical approaches using Python statistical analysis software., Methods: We selected four common complex pediatric surgical conditions (choledochal cyst, Hirschsprung's disease, vesicoureteral reflux, and congenital hydronephrosis) from three systems (pediatric hepatobiliary, gastroenterology, and urology). Models were constructed using Python statistical software to compare hospital costs and surgical outcomes for RALS and LS. In addition, we performed a preferred strategy analysis for both surgical modalities while assessing model uncertainty using one-way sensitivity analysis., Results: For the four diseases, the operative time decreased sequentially. The total inpatient costs of RALS were 10,816.72, 9145.44, 8414.29, 7973.58 dollars, respectively, yielding 1.789, 1.712, 1.749, 1.792 quality adjustment life years (QALYs) over two years post-operatively. The incremental cost of RALS relative to LS for each disease was 3523.44, 3200.20, 3049.79, 3043.66 dollars, respectively, with an incremental utility of 0.060, 0.054, 0.051, 0.050 QALYs. The incremental cost-effectiveness ratios (ICERs) for RALS for each of the four diseases were 58,724.01, 59,262.95, 59,799.79, 60,873.20 dollars/QALY, all less than 100,000 dollars/QALY. The cost of robot consumables was the main incremental cost of RALS and had the most significant impact on the model., Conclusion: For the four pediatric surgical conditions described above, RALS has higher inpatient costs than LS, but it has better postoperative outcomes, and all four RALS treatments are cost-effective. Children with complex diseases and long operative times appear to benefit more from RALS., (© 2023. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)