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Several studies report on a learning curve for robotic pancreatoduodenectomy (R-PD) ranging between 20 and 80 operations, with conversion rates varying between 1.1 and 35%. However, as these publications mostly refer to initial robotic experiences and do not take into account the previous surgical background in pancreatic surgery (PS) and in robotic-assisted surgery (RAS), the center's volume, as well as the platform used, we aimed to perform a surgical outcomes analysis with a particular view to these aspects.Intraoperative and perioperative outcomes of the first 50 consecutive R-PD performed with the da Vinci Xi by the same surgeon, within a tertiary referral high-volume center, between January 2018 and March 2022, were analyzed. The surgeon was previously experienced in both PS and RAS. Shewhart control chart and cumulative sum (CUSUM) analysis were used to evaluate the learning curve of R-PD.All the operations were performed with a full-robotic technique, without any conversion to open surgery. Twenty of 50 patients (40%) had a BMI ≥ 25 kg/mAn extensive prior experience in both PS and RAS, within a tertiary referral high-volume center with availability of the da Vinci Xi platform, can significantly flatten the learning curve and, therefore, enable safe performance of challenging operations, i.e., pancreatoduodenectomies with a minimally invasive approach, with very low risk of conversion to open surgery, even in the first 50 operations.

Worldwide up to May 2022 there have been 515 million cases of COVID-19 infection and over 6 million deaths. The World Health Organization estimated that 115,000 healthcare workers died from COVID-19 from January 2020 to May 2021. This toll on human lives prompted this review on 5G based networking primarily on major components of healthcare delivery: diagnosis, patient monitoring, contact tracing, diagnostic imaging tests, vaccines distribution, emergency medical services, telesurgery and robot-assisted tele-ultrasound. The positive impact of 5G as core technology for COVID-19 applications enabled exchange of huge data sets in fangcang (cabin) hospitals and real-time contact tracing, while the low latency enhanced robot-assisted tele-ultrasound, and telementoring during ophthalmic surgery. In other instances, 5G provided a supportive technology for applications related to COVID-19, e.g., patient monitoring. The feasibility of 5G telesurgery was proven, albeit by a few studies on real patients, in very low samples size in most instances. The important future applications of 5G in healthcare include surveillance of elderly people, the immunosuppressed, and nano- oncology for Internet of Nano Things (IoNT). Issues remain and these require resolution before routine clinical adoption. These include infrastructure and coverage; health risks; security and privacy protection of patients' data; 5G implementation with artificial intelligence, blockchain, and IoT; validation, patient acceptance and training of end-users on these technologies.

BACKGROUND Large language models are capable of answering questions as if they were engaged in active conversation with users. However, currently, there are no data on whether their performances will remain static or vary over time when answering questions in the medical domain. OBJECTIVE The aim of the present study was to assess ChatGPT and InstructGPT on multiple trials on the Fundamentals of Robotic Surgery (FRS) test. Additionally, different releases of ChatGPT were compared to establish whether its performance improved after retraining. METHODS We tested the performance of ChatGPT and InstructGPT on the 44 multiple choice questions of FRS didactic test, for which a pass mark requires 35 correct answers (79.5%). Seven attempts were performed using ChatGPT on the January 30, 2023 release and seven with the February 13, 2023 version. Three trials were performed with InstructGPT. RESULTS ChatGPT achieved a mean score of 64.6% and 65.6% respectively for the first and second release, without any significant difference between the two (p = 0.32). The score ranged from 54.5% to 72.7% with both versions. On baseline it achieved 54.5% in both releases, higher than InstructGPT (50.0%). The highest rate of correct answers of ChatGPT was observed for questions on team training and communication (77.5% with both releases), followed by those on the introduction of the robotic system (67.5% and 62.7 % respectively for the first and second versions), psychomotor skills (64.3% and 57.1%), and naming correctly clinical steps of a procedure of robot-assisted surgery (53.8% and 65.9%). CONCLUSIONS Even though ChatGPT did not pass FRS test in any of the 14 trials, the 72.7% score observed by the present study represents a remarkable result, taking into consideration the generic nature of ChatGPT as distinct from a domain specific LLM. This level represents the highest score by ChatGPT in a high-stake examination in medicine.

A novel endoscopic multi-firing clip applicator (EMFCA) system was developed for closing large perforations, in which the clips was deployed by pushing through a tendon-sheath actuation system (TSAS). However, the closure performance is heavily dependent on the pushing force transmitted to the clips which shows different nonlinear characteristics comparing with pulling transmission. Therefore, this study aimed to develop a pushing transmission model of the TSAS for precise control of the EMFCA, and verify its applicability. A pushing transmission model of the TSAS was proposed and simulated. Meanwhile, a TSAS-based push-transmission platform was designed to identify the parameters which potentially affect the transmission efficiency. Besides, ex vivo endoscopic stomach perforation closure experiments were carried out with the EMFCA system to validate the reliability of the proposed model. The experiment indicated that the results of simulation had a satisfactory agreement with the experimental data. The force and displacement transmission presented a linear relationship during the loading and unloading period, and the transmission efficiency and dead zone were affected by the tendon-sheath diameter ratio and the curvature. The ex-vivo testing revealed that a superior closure was obtained by using the EMFCA through effective deformation of the clip to anchor loop tightly onto the tissue when the input forces were in the range of 21–30 N. The proposed pushing transmission model could provide a reliable prediction of force feedback which contributes to accuracy control of the flexible endoscopic instrument with TSAS and improving the safety of endoscopic surgery.

Background The literature on artificial intelligence (AI) in surgery has advanced rapidly during the past few years. However, the published studies on AI are mostly reported by computer scientists using their own jargon which is unfamiliar to surgeons. Methods A literature search was conducted in using PubMed following the preferred reporting items for systematic reviews and meta-analyses (PRISMA) statement. The primary outcome of this review is to provide a glossary with definitions of the commonly used AI terms in surgery to improve their understanding by surgeons. Results One hundred ninety-five studies were included in this review, and 38 AI terms related to surgery were retrieved. Convolutional neural networks were the most frequently culled term by the search, accounting for 74 studies on AI in surgery, followed by classification task (n = 62), artificial neural networks (n = 53), and regression (n = 49). Then, the most frequent expressions were supervised learning (reported in 24 articles), support vector machine (SVM) in 21, and logistic regression in 16. The rest of the 38 terms was seldom mentioned. Conclusions The proposed glossary can be used by several stakeholders. First and foremost, by residents and attending consultant surgeons, both having to understand the fundamentals of AI when reading such articles. Secondly, junior researchers at the start of their career in Surgical Data Science and thirdly experts working in the regulatory sections of companies involved in the AI Business Software as a Medical Device (SaMD) preparing documents for submission to the Food and Drug Administration (FDA) or other agencies for approval.

Background Colonoscopy is a widely used and effective procedure, but it often causes patient discomfort and its execution requires considerable skill and training. We demonstrate an alternative approach to colonoscope propulsion with the potential to minimise patient discomfort by reducing the forces exerted on the colonic wall and mesentery, and to reduce the level of skill required for execution. Methods A prototype colonoscopic device is described, consisting of a tethered capsule that is propelled and manoeuvred through a water-filled colon (hydro-colonoscopy) by an array of water jets. As an initial proof of concept, experiments were performed to assess the ability of the device to navigate through a simplified PVA cryogel human colon phantom arranged in various anatomical configurations. Results The prototype was capable of successfully navigating through three out of four colon configurations: a simple layout, alpha loop and reverse alpha loop. It was unable to negotiate the fourth configuration involving an “N loop”, but this was attributed to problems with the colon phantom. In the successful test replicates, mean complete insertion (i.e. caecal intubation) time was 4.7 min. Measured pressures, temperatures and forces exerted on the colon appeared to be within a physiologically acceptable range. The results demonstrate the viability of propelling a colonoscope through a colon phantom using hydro-jets. Conclusions Results indicate that this approach has the potential to enable rapid and safe caecal intubation. This suggests that further development towards clinical translation is worthwhile.

Background Difficulties in establishing diagnosis of small bowel (SB) disorders, prevented their effective treatment. This problem was largely resolved by wireless capsule endoscopy (WCE), which has since become the first line investigation for suspected SB disorders. Several types of WCE pills are now used in clinical practice, despite their limitations and complications. WCE pills are large, rigid and immotile capsules. When swallowed, they provide SB enteroscopy downloaded to a data logger carried by the patient. Most of the complications of WCEs result from lack of intrinsic locomotion: incomplete examination, capsule retention and impaction within strictures. In addition, the rigid nature and size of current generation of WCE pills is accompanied by 0.1% inability to swallow the pill by patients with normal esophageal motility. Methods The aim of this communication is to describe the initial prototype, P1, which is thinner and slightly longer than the current generation of WCEs. In addition, it exhibits intrinsic active locomotion, produced by vibrating silicon legs. These generate a controlled-skid locomotion on the small bowel mucosal surface, rendered slippery by surface mucus and intraluminal surfactant bile salts. We demonstrate the mechanism responsible for the active locomotion of P1, which we consider translatable into a working prototype, suitable for further R&D for eventual clinical translation. Results The shape and attachment of the rubber vibrating legs to vibrating actuators, have been designed specifically to produce a tight clockwise circular motion. When inserted inside a circular tube in vitro of equivalent diameter to human small intestine, the intrinsic circular clockwise motion of P1 translates into a linear locomotion by the constraints imposed by the surrounding circular walls of SB and rest of the gastrointestinal tract. This design ensures device stability during transit, essential for imaging and targeting lesions encountered during the enteroscopy. We preformed two experiments: (i) transit of P1 through a phantom consisting of a segment of PVC tube placed on a horizontal surface and (ii) transit through a transparent slippery nylon sleeve insufflated with air. In the PVC tube, its transit rate averages 15.6 mm/s, which is too fast for endoscopy: whereas inside the very slippery nylon sleeve insufflated with air, the average transit rate of P1 is reduced to 5.9 mm/s, i.e., ideal for inspection endoscopy. Conclusions These in-vitro experiments indicate that the P1 hybrid soft robot prototype has the potential specifically for clinical translation for SB enteroscopy.

Background Artificial intelligence (AI) has the potential to enhance patient safety in surgery, and all its aspects, including education and training, will derive considerable benefit from AI. In the present study, deep-learning models were used to predict the rates of proficiency acquisition in robot-assisted surgery (RAS), thereby providing surgical programs directors information on the levels of the innate ability of trainees to facilitate the implementation of flexible personalized training. Methods 176 medical students, without prior experience with surgical simulators, were trained to reach proficiency in five tasks on a virtual simulator for RAS. Ensemble deep neural networks (DNN) models were developed and compared with other ensemble AI algorithms, i.e., random forests and gradient boosted regression trees (GBRT). Results DNN models achieved a higher accuracy than random forests and GBRT in predicting time to proficiency, 0.84 vs. 0.70 and 0.77, respectively (Peg board 2), 0.83 vs. 0.79 and 0.78 (Ring walk 2), 0.81 vs 0.81 and 0.80 (Match board 1), 0.79 vs. 0.75 and 0.71 (Ring and rail 2), and 0.87 vs. 0.86 and 0.84 (Thread the rings 2). Ensemble DNN models outperformed random forests and GBRT in predicting number of attempts to proficiency, with an accuracy of 0.87 vs. 0.86 and 0.83, respectively (Peg board 2), 0.89 vs. 0.88 and 0.89 (Ring walk 2), 0.91 vs. 0.89 and 0.89 (Match board 1), 0.89 vs. 0.87 and 0.83 (Ring and rail 2), and 0.96 vs. 0.94 and 0.94 (Thread the rings 2). Conclusions Ensemble DNN models can identify at an early stage the acquisition rates of surgical technical proficiency of trainees and identify those struggling to reach the required expected proficiency level.

The essence of this new surgical approach is the reduction of the trauma of access; hence the appropriate name is Minimal Access Surgery (MAS). Laparoscopic cholecystectomy has changed surgical practice across all the surgical disciplines and even changed current open surgical practice by earlier ambulation and reduction of hospital stay. The likely way ahead in specialist care of patients might well follow a new paradigm in the quest for improved patient outcome and further reduction of the traumatic insult to the patient by a new team approach of MAT (Minimal Access Therapy).

We report a one-step synthesis protocol for obtaining polymer-coated magnetic nanoparticles (MNPs) engineered for uploading neural cells. Polyethyleneimine-coated Fe

Background The treatment of the pancreatic stump is a critical step of pancreatoduodenectomy (PD). Robot-assisted surgery (RAS) can facilitate minimally invasive challenging abdominal procedures, including pancreatojejunostomy. However, one of the major limitations of RAS stems from its lack of tactile feedback that can lead to pancreatic parenchyma laceration during knot tying or during traction on the suture. Moreover, a Wirsung-jejunostomy is not always easy to execute, especially in cases with small diameter duct. Herein, we describe and video-report the technical details of a robotic modified end-to-side invaginated robotic pancreatojejunostomy (RmPJ) with the use of barbed suture instead of the “classical” Wirsung-jejunostomy. Methods The RmPJ technique consists of a double layer of absorbable monofilament running barbed suture (3–0 V-Loc), the outer layer is used to invaginate the pancreatic stump. Thereafter, a small enterotomy is made in the jejunum exactly opposite to the location of the pancreatic duct for stent insertion (usually 5 Fr) inside the duct. The internal layer provides a second barbed running suture placed between the pancreatic capsule/parenchyma and the jejunal seromuscular layer. Results A total of 14 patients underwent robotic PD with RmPJ at our Institution. The mean console time was (281.36 ± 31.50 min), while the mean operative time for fashioning the RmPJ was 37.31 ± 7.80 min. Ten out of 14 patients were discharged within postoperative day 8. No clinically relevant pancreatic fistulas were encountered, while two patients developed biochemical leaks. Conclusions RmPJ is feasible and reproducible irrespective of pancreatic duct size and parenchyma, and can enhance the surgical workflow of this operation. Specifically, the use of barbed sutures allows the exploitation of the potential advantages of the RAS, while minimizing the negative effect caused by the main disadvantage of the robotic approach, its absence of tactile feedback, by ensuring uniform tension on the continuous suture lines used, especially during the reconstructive phase of the operation.

Purpose. To investigate the oncological outcome and survival of patients following a conservative approach on the portal-mesenteric axis, in an intraoperative ultrasound-selected group of pancreatoduodenectomy (PD), performed on patients with primary resectable with vascular contact (prVC) pancreatic ductal adenocarcinoma (PDAC). Methods. A consecutive series of patients who underwent PD for PDAC at our tertiary care center, between 2008 and 2017, were reviewed. A total of 156 PDs and 88 total pancreatectomies were performed during the study period, including 35 vascular resections. We identified a group of 40 (25.6%) patients with prVC-PDAC in whom after checking the feasibility with intraoperative ultrasound, we were able to perform PD by separation of the tumor from the portomesenteric axis avoiding vascular resection, without residual macroscopic disease (no vascular resection, nvrPD), and compared this group, using case-matched methodology, with the standard PD (sPD) group of primary resectable without vascular contact- (prwVC-) PDAC. Results. The median follow-up was 28.5 ± 23.2 months in the sPD group and 23.8 ± 20.8 months in the nvrPD group (p=0.35). Isolated local recurrence rate was 2/40 (5%) in both groups. Additionally, there were no statistical differences in the systemic progression of the disease (42.5% sPD vs. 45% nvrPD, p=0.82) or local plus synchronous systemic disease rates (2.5% sPD vs. 7.5% nvrPD, p=0.30). The median survival was 22 months for the sPD group and 23 months for the nvrPD group, p=0.86. The overall survival was similar in the two groups (1 y: 76.3% sPD vs. 70.0% nvrPD; 3 y: 35.6% vs. 31.6%; and 5 y: 28.5% vs. 25.3%; p=0.80). Conclusions. PD without vascular resection can be considered safe and oncologically acceptable in selected patients with preoperative diagnosis of prVC-PDAC. The poor prognosis of PDAC is related to the aggressive biology and systemic spread of the tumor, rather than the local control of the disease.

Investigations over half a century have indicated that mechanical forces induce neurite growth - with neurites elongating at a rate of 0.1-0.3{\mu}mh^{-1} per pico-Newton (pN) of applied force - when mechanical tension exceeds a threshold, with this being identified as 400-1000 pN for neurites of PC12 cells. Here we demonstrate that there is no threshold for neurite elongation of PC12 cells in response to applied mechanical forces. Instead, this proceeds at the same previously identified rate, on the application of tensions with intensity below 1pN. This supports the idea of mechanical tension as an endogenous signal used by neurons for promoting neurite elongation., Comment: 16 pages, 3 figures

There is an increasing interest for a test assessing objectively the innate aptitude for surgery as a craft specialty to complement the current selection process of surgical residents. The aim of this study was to quantify the size of individuals with high, average, and low level of innate psychomotor skills among medical students. A volunteer sample of 155 medical students, without prior experience with surgical simulator, executed five tasks at a virtual simulator for robot-assisted surgery. They had to reach proficiency twice consecutively in each before moving to the next one. A weighting based on time and number of attempts needed to reach proficiency was assigned to each task. Nine students (5.8%) out of 155 significantly outperformed all the others on median (i.q.r.) weighted time [44.7 (42.2–47.3) min vs. 98.5 (70.8–131.8) min, p

Holographic optical tweezers (HOT) hold great promise for many applications in biophotonics, allowing the creation and measurement of minuscule forces on biomolecules, molecular motors and cells. Geometries used in HOT currently rely on bulk optics, and their exploitation in vivo is compromised by the optically turbid nature of tissues. We present an alternative HOT approach in which multiple three-dimensional (3D) traps are introduced through a high-numerical-aperture multimode optical fibre, thus enabling an equally versatile means of manipulation through channels having cross-section comparable to the size of a single cell. Our work demonstrates real-time manipulation of 3D arrangements of micro-objects, as well as manipulation inside otherwise inaccessible cavities. We show that the traps can be formed over fibre lengths exceeding 100 mm and positioned with nanometric resolution. The results provide the basis for holographic manipulation and other high-numerical-aperture techniques, including advanced microscopy, through single-core-fibre endoscopes deep inside living tissues and other complex environments. Through a high-numerical-aperture multimode fibre, real-time manipulation of three-dimensional arrangements of micro-objects and manipulation inside inaccessible cavities are shown. The approach is useful for imaging deep inside living tissues and complex environments.

Background Despite the extensive published literature on the significant potential of artificial intelligence (AI) there are no reports on its efficacy in improving patient safety in robot-assisted surgery (RAS). The purposes of this work are to systematically review the published literature on AI in RAS, and to identify and discuss current limitations and challenges. Materials and methods A literature search was conducted on PubMed, Web of Science, Scopus, and IEEExplore according to PRISMA 2020 statement. Eligible articles were peer-review studies published in English language from January 1, 2016 to December 31, 2020. Amstar 2 was used for quality assessment. Risk of bias was evaluated with the Newcastle Ottawa Quality assessment tool. Data of the studies were visually presented in tables using SPIDER tool. Results Thirty-five publications, representing 3436 patients, met the search criteria and were included in the analysis. The selected reports concern: motion analysis (n = 17), urology (n = 12), gynecology (n = 1), other specialties (n = 1), training (n = 3), and tissue retraction (n = 1). Precision for surgical tools detection varied from 76.0% to 90.6%. Mean absolute error on prediction of urinary continence after robot-assisted radical prostatectomy (RARP) ranged from 85.9 to 134.7 days. Accuracy on prediction of length of stay after RARP was 88.5%. Accuracy on recognition of the next surgical task during robot-assisted partial nephrectomy (RAPN) achieved 75.7%. Conclusion The reviewed studies were of low quality. The findings are limited by the small size of the datasets. Comparison between studies on the same topic was restricted due to algorithms and datasets heterogeneity. There is no proof that currently AI can identify the critical tasks of RAS operations, which determine patient outcome. There is an urgent need for studies on large datasets and external validation of the AI algorithms used. Furthermore, the results should be transparent and meaningful to surgeons, enabling them to inform patients in layman's words. Registration Review Registry Unique Identifying Number: reviewregistry1225.

Heartbeat classification is a crucial step for arrhythmia diagnosis during electrocardiographic (ECG) analysis. The new scenario of wireless body sensor network- (WBSN-) enabled ECG monitoring puts forward a higher-level demand for this traditional ECG analysis task. Previously reported methods mainly addressed this requirement with the applications of a shallow structured classifier and expert-designed features. In this study, modified frequency slice wavelet transform (MFSWT) was firstly employed to produce the time-frequency image for heartbeat signal. Then the deep learning (DL) method was performed for the heartbeat classification. Here, we proposed a novel model incorporating automatic feature abstraction and a deep neural network (DNN) classifier. Features were automatically abstracted by the stacked denoising auto-encoder (SDA) from the transferred time-frequency image. DNN classifier was constructed by an encoder layer of SDA and a softmax layer. In addition, a deterministic patient-specific heartbeat classifier was achieved by fine-tuning on heartbeat samples, which included a small subset of individual samples. The performance of the proposed model was evaluated on the MIT-BIH arrhythmia database. Results showed that an overall accuracy of 97.5% was achieved using the proposed model, confirming that the proposed DNN model is a powerful tool for heartbeat pattern recognition.

The performance of a soft pneumatic robot (SPR) relies on the synergy between the mechanical design and the control unit that implements a closed-loop control between sensors and actuators. Most controllers are designed by using off-the-shelf components. Although commercial parts present high precision and reliability, they are heavy and bulky, limiting the realisation and design of untethered robots. The present study describes a wireless pneumatic control unit of a compact and light design that can control up to 3 pneumatic chambers. The unit includes pressure sensors and high precision miniaturised proportional valves. To simplify both the electrical cabling and the air tubes connections, a compact manifold is used to connect valves and pressure sensors. The control unit uses a Bluetooth RS232 serial module for a wireless communication. The mechatronic design is reported describing the electronic hardware, the manifold solution, and the firmware implementation. Experiments report i) the control of a linear pneumatic actuator (LPA), and ii) a simultaneous activation of 3 LPAs connected to a base providing 3 degrees of freedom (DOFs).

This study reports a novel Hollow Soft Pneumatic Actuator (HOSE), which exhibits 4 degrees of freedom (DOFs). The design consists of a central hollow cylinder surrounded by four twisting symmetric chambers. By virtue of their spiral disposition, each chamber produces a diagonal force along the hollow internal cylinder composed of two components: one parallel to the Z axis and the other one to the plane X-Y. Both top and bottom sections of the actuator are reinforced to avoid deformation, essential for optimal function and dexterity of HOSE. Different movements of the actuator are produced by varying the activation combinations of the 4 chambers. They are constructed from thin walled (0.5 mm) Ecoflex 00–30 super soft silicon rubber, enabling HOSE to perform controlled movements with low pressure not exceeding 35 kPa. HOSE exhibits a maximal extension of 230% of its original length, bends up to i) ±900 around X axis, ii) ±1150 around Y axis, and iii) twists around Z axis with a total range of ±350. The paper describes the manufacturing process together with the actuator performance, reporting the range of motion along each DOF related to the internal pressure, volume versus forces and torques produced along each axis.

The design of a smart robot for colonoscopy is challenging because of the limited available space, slippery internal surfaces, and tortuous 3D shape of the human colon. Locomotion forces applied by an endoscopic robot may damage the colonic wall and/or cause pain and discomfort to patients. This study reports a Soft Pneumatic Inchworm Double balloon (SPID) mini-robot for colonoscopy consisting of two balloons connected by a 3 degrees of freedom soft pneumatic actuator. SPID has an external diameter of 18 mm, a total length of 60 mm, and weighs 10 g. The balloons provide anchorage into the colonic wall for a bio-inspired inchworm locomotion. The proposed design reduces the pressure applied to the colonic wall and consequently pain and discomfort during the procedure. The mini-robot has been tested in a deformable plastic colon phantom of similar shape and dimensions to the human anatomy, exhibiting efficient locomotion by its ability to deform and negotiate flexures and bends. The mini-robot is made of elastomer and constructed from 3D printed components, hence with low production costs essential for a disposable device.

Background Conventional colonoscopy requires a high degree of operator skill and is often painful for the patient. We present a preliminary feasibility study of an alternative approach where a self-propelled colonoscope is hydraulically driven through the colon. Methods A hydraulic colonoscope which could be controlled manually or automatically was developed and assessed in a test bed modelled on the anatomy of the human colon. A conventional colonoscope was used by an experienced colonoscopist in the same test bed for comparison. Pressures and forces on the colon were measured during the test. Results The hydraulic colonoscope was able to successfully advance through the test bed in a comparable time to the conventional colonoscope. The hydraulic colonoscope reduces measured loads on artificial mesenteries, but increases intraluminal pressure compared to the colonoscope. Both manual and automatically controlled modes were able to successfully advance the hydraulic colonoscope through the colon. However, the automatic controller mode required lower pressures than manual control, but took longer to reach the caecum. Conclusions The hydraulic colonoscope appears to be a viable device for further development as forces and pressures observed during use are comparable to those used in current clinical practice.

Background: Cystic pancreatic lesions (CPLs) are being identified increasingly, and some benefit from surgical treatment. With the increasing use of robotic-assisted surgery (RAS) for neoplasms of the pancreas, the aim of the present comparative study is to establish whether the RAS offered any advantages over conventional open surgery (OS) in the management of CPLs. Patients and Methods: Twenty-seven out of 37 robot-assisted left-sided pancreatectomy (LSP) performed between January 2010 and April 2017 were carried out for CPLs. The surgical outcome and histopathology were compared retrospectively with a control group of 27 patients who had undergone open LSP for CPLs, selected using a one-to-one case-matched methodology (OS-Group) from the prospectively collected institutional database. Results: The spleen was preserved in a significantly higher percentage of patients in the RAS-group (63% vs. 33.3%, P < 0.05). There was no difference in the post-operative course (pancreatic fistula and morbidity) between the two groups. The median post-operative hospital stay was significantly shorter in the RAS-group: 8 days (range 3–25) versus 12 days (range 7–26) in the OS-group (P < 0.01). No conversion to open approach was reported in the RAS-group. Conclusions: Robotically assisted LSP is a safe and effective procedure. It is accompanied by a significantly higher spleen preservation rate compared to the open approach. In addition, because of the reduced trauma, RAS incurred a shorter post-operative hospital stay and faster return to full recovery, particularly important in patients undergoing surgery for relative indications. However, these benefits of RAS for LSP require confirmation by prospective randomised controlled studies.

Fibre-based optical tweezers typically rely on engineered fibre terminations yielding limited flexibility in number and positioning of trap sites. Here, we demonstrate holographic optical tweezers delivered by a lensless, high-NA multimode fibre with full positioning control of multiple tweezers independently and in all directions.

Robotic-assisted surgery by the da Vinci Si appears to benefit rectal cancer surgery in selected patients, but still has some limitations, one of which is its high costs. Preliminary studies have indicated that the use of the new da Vinci Xi provides some added advantages, but their impact on cost is unknown. The aim of the present study is to compare surgical outcomes and costs of rectal cancer resection by the two platforms, in a single surgeon’s experience. From April 2010 to April 2017, 90 robotic rectal resections were performed, with either the da Vinci Si (Si-RobTME) or the da Vinci Xi (Xi-RobTME). Based on CUSUM analysis, two comparable groups of 40 consecutive Si-RobTME and 40 consecutive Xi-RobTME were obtained from the prospectively collected database and used for the present retrospective comparative study. Data costs were analysed based on the level of experience on the proficiency–gain curve (p–g curve) by the surgeon with each platform. In both groups, two homogeneous phases of the p–g curve were identified: Si1 and Xi1: cases 1–19, Si2 and Xi2: cases 20–40. A significantly higher number of full RAS operations were achieved in the Xi-RobTME group (p

The new generation of bio-inspired robots is constructed from soft materials. The low mechanical stiffness of the material enables continuous deformation by the robot, which can thus negotiate narrow and tortuous spaces. Additionally, soft robots are intrinsically atraumatic, with safe interaction with the surrounding environment without the need of an active compliant control. Several research centres are exploring solutions to vary the stiffness of the component material through use of either on-off or continuous mechanisms. The latter can be implemented by using a combination of pneumatic chambers and tendons to vary the air pressure, in a single compact design. To enhance the robot dexterity required to perform complex tasks, each module of the soft robot needs to exhibit several degrees of freedom (DOFs). In the present study, we describe a novel soft pneumatic cylindrical module made of fibre-reinforced polymer, that uses 2 pair disposed antagonistic tendons for variable stiffness control and capable of 4 DOFs. By tensioning twin pairs of antagonistic tendons, the module can rotate around X, Y and Z axes, and by inflating air in the 2 chambers, it can extend along Z but also rotate around the X axis. The wide cross-sectional area of the chamber reduces the maximal actuating internal air pressure. We report the design and construction of the soft module, and experimental data on the range of motion, forces generated, and the range of stiffness.

Aims: The role of minimally invasive surgery of gastrointestinal stromal tumours (GISTs) of the stomach remains uncertain especially for large and/or difficult located tumours. We are hereby presenting a single-centre series of robot-assisted resections using the da Vinci Surgical System (Si or Xi). Subjects and Methods: Data of patients undergoing robot-assisted treatment of gastric GIST were retrieved from the prospectively collected institutional database and a retrospective analysis was performed. Patients were stratified according to size and location of the tumour. Difficult cases (DCs) were considered for size if tumour was >50 mm and/or for location if the tumour was Type II, III or IV sec. Privette/Al-Thani classification. Results: Between May 2010 and February 2017, 12 consecutive patients underwent robot-assisted treatment of GIST at our institution. DCs were 10/12 cases (83.3%), of which 6/10 (50%) for location, 2/10 (25%) for size and 2/10 (25%) for both. The da Vinci Si was used in 8 patients, of which 6 (75%) were DC, and the da Vinci Xi in 4, all of which (100%) were DC. In all patients, excision was by wedge resection. All lesions had microscopically negative resection margins. There was no conversion to open surgery, no tumour ruptures or spillage and no intraoperative complications. Conclusion: Our experience suggests a positive role of the robot da Vinci in getting gastric GIST removal with a conservative approach, regardless of size and location site. Comparative studies with a greater number of patients are necessary for a more robust assessment.

Background. The da Vinci Table Motion (dVTM) is a new device that enables patients to be repositioned with instruments in place within the abdomen, and without undocking the robot. The present study was designed to compare operative and short-term outcomes of patients undergoing colorectal cancer surgery with the da Vinci Xi system, with or without use of the dVTM. Methods. Ten patients underwent robotic colorectal resection for cancer with the use of dVTM (Xi-dVTM group) between May 2015 and October 2015 at our center. The intraoperative and short-term clinical outcome were compared, using a case-control methodology (propensity scores approach to create 1:2 matched pairs), with a similar group of patients who underwent robotic colorectal surgery for cancer without the use of the dVTM device (Xi-only group). Results. Overall robotic operative time was shorter in the Xi-dVTM group ( P = .04). Operations were executed fully robotic in all Xi-dVTM cases, while 2 cases of the Xi-only group required conversion to open surgery because of bulky tumors and difficult exposure. Postoperative medical complications were higher in the Xi-only group ( P = .024). Conclusions. In this preliminary experience, the use of the new dVTM with the da Vinci Xi in colorectal surgery, by overcoming the limitations of the fixed positions of the patient, enhanced the workflow and resulted in improved exposure of the operative field. Further studies with a greater number of patients are needed to confirm these benefits of the dVTM-da Vinci Xi robotically assisted colorectal surgery.

The 3-D spatial and mechanical features of nano-topography can create alternative environments, which influence cellular response. In this paper, murine fibroblast cells were grown on surfaces characterized by protruding nanotubes. Cells cultured on such nano-structured surface exhibit stronger cellular adhesion compared to control groups, but despite the fact that stronger adhesion is generally believed to promote cell cycle progression, the time cells spend in G1 phase is doubled. This apparent contradiction is solved by confocal microscopy analysis, which shows that the nano-topography inhibits actin stress fiber formation. In turn, this impairs RhoA activation, which is required to suppress the inhibition of cell cycle progression imposed by p21/p27. This finding suggests that the generation of stress fibers, required to impose the homeostatic intracellular tension, rather than cell adhesion/spreading is the limiting factor for cell cycle progression. Indeed, nano-topography could represent a unique tool to inhibit proliferation in adherent well-spread cells.

Robotic rectal resection with da Vinci Si has some technical limitations, which could be overcome by the new da Vinci Xi. We compare short-term surgical and functional outcomes following robotic rectal resection with total mesorectal excision for cancer, with the da Vinci Xi (Xi-RobTME group) and the da Vinci Si (Si-RobTME group).The first consecutive 30 Xi-RobTME were compared with a Si-RobTME control group of 30 patients, selected using a one-to-one case-matched methodology from our prospectively collected Institutional database, comprising all cases performed between April 2010 and September 2016 by a single surgeon. Perioperative outcomes were compared. The impact of minimally invasive TME on autonomic function and quality of life was analyzed with specific questionnaires.The docking and overall operative time were shorter in the Xi-RobTME group (p 0.001 and p 0.05 respectively). The mean differences of overall operative time and docking time were -33.8 min (95% CI -5.1 to -64.5) and -6 min (95% CI -4.1 to -7.9), respectively. A fully-robotic approach with complete splenic flexure mobilization was used in 30/30 (100%) of the Xi-RobTME cases and in 7/30 (23%) of the Si-RobTME group (p 0.001). The hybrid approach in males and patients with BMI 25 kg/mThe technical advantages offered by the da Vinci Xi seem to be mainly associated with a shorter docking and operative time and with superior ability to perform a fully-robotic approach. Clinical and functional outcomes seem not to be improved, with the introduction of the new Xi platform.

Conventional laparoscopic instruments used for retraction may cause trauma at the retraction site. Alternative retraction/lifting especially of heavy solid organs such as the liver may be obtained by other means. The present study was designed to explore the use of C3-muco-adhesive polymers (C3-MAPs), which exhibit strong binding to the liver shortly after application to the organ and which retain strong adhesion for sufficient time, to enable sustained retraction during laparoscopic operations. C3-muco-adhesive polymers were produced specifically for the study. In an ex vivo experimental set-up, discs of C3-MAPs were placed on the surface of porcine livers for adhesion and retraction studies involving objective measurements by tensiometry. Experiments were carried out on 14 porcine livers. The force required to detach the C3-MAPs from the liver exceeded 2.0 N 30 s after application. The adhesion force by C3-MAPs files was sufficient to enable sustained retraction force necessary for exposure of the gall bladder, which was achieved by a mean retraction force of 4.85 N (SD = 0.63). This was sustained for a mean of 130 min (range 17.0–240.0). In the adhesion studies, the forces at 30 s required to detach the polymer discs from the liver exceeded 20 N (upper limit of the load cells of the Instron). The duration of the adhesion enabled sustained optimal gall bladder exposure for periods ranging from 17 to 240 min, with a mean of 130 ± 91 min. The results of the present study demonstrate that the adhesion and retraction properties of the engineered C3-MAP films are sufficient to enable complete exposure of the gall bladder for a period exceeding 1 h, confirming their potential for atraumatic retraction in laparoscopic and other minimal-access surgical approaches.

Previous reports have described several candidates, which have the potential to replace colonoscopy, but to date, there is still no device capable of fully replacing flexible colonoscopy in the management of colonic disorders and for mass adult population screening for asymptomatic colorectal cancer. NASA developed the TRL methodology to describe and define the stages of development before use and marketing of any device. The definitions of the TRLS used in the present review are those formulated by “The US Department of Defense Technology Readiness Assessment Guidance” but adapted to micro-robots for colonoscopy. All the devices included are reported in scientific literature. They were identified by a systematic search in Web of Science, PubMed and IEEE Xplore amongst other sources. Devices that clearly lack the potential for full replacement of flexible colonoscopy were excluded. The technological salient features of all the devices included for assessment are described briefly, with particular focus on device propulsion. The devices are classified according to the TRL criteria based on the reported information. An analysis is next undertaken of the characteristics and salient features of the devices included in the review: wireless/tethered devices, data storage–transmission and navigation, additional functionality, residual technology challenges and clinical and socio-economical needs. Few devices currently possess the required functionality and performance to replace the conventional colonoscopy. The requirements, including functionalities which favour the development of a micro-robot platform to replace colonoscopy, are highlighted.

The magnetic signals from magnetite nanoparticle-labeled PC12 cells were assessed by magnetic force microscopy by deploying a localized external magnetic field to magnetize the nanoparticles and the magnetic tip simultaneously so that the interaction between the tip and PC12 cell-associated Fe3O4 nanoparticles could be detected at lift heights (the distance between the tip and the sample) larger than 100 nm. The use of large lift heights during the raster scanning of the probe eliminates the non-magnetic interference from the complex and rugged cell surface and yet maintains the sufficient sensitivity for magnetic detection. The magnetic signals of the cell-bound nanoparticles were semi-quantified by analyzing cell surface roughness upon three-dimensional reconstruction generated by the phase shift of the cantilever oscillation. The obtained data can be used for the evaluation of the overall cellular magnetization as well as the maximum magnetic forces from magnetic nanoparticle-labeled cells which is crucial for the biomedical application of these nanomaterials.

As a new signal processing tool, a Modified frequency slice wavelet transform (MFSWT) is proposed for physiological signal time-frequency analysis in this study. The transform generates time-frequency representation from the frequency domain, and the reconstruction is independent of frequency slice function (FSF). To realize accurate time-frequency location of signal components, a bound signal-adaptive FSF was introduced to serve as a dynamic frequency filter for the transform. This method avoids troublesome parameter selection, is signal-adaptive and easy to use. The results of two case studies demonstrate the validity of the proposed method, which has good interpretability with high time-frequency resolution, and hence has significant potential for bio-signal time-frequency analysis.