Robotic and robot-assisted skull base neurosurgery: systematic review of current applications and future directions

OBJECTIVE The utility of robotic instrumentation is expanding in neurosurgery. Despite this, successful examples of robotic implementation for endoscopic endonasal or skull base neurosurgery remain limited. Therefore, the authors performed a systematic review of the literature to identify all articles that used robotic systems to access the sella or anterior, middle, or posterior cranial fossae. METHODS A systematic review of MEDLINE and PubMed in accordance with PRISMA guidelines performed for articles published between January 1, 1990, and August 1, 2021, was conducted to identify all robotic systems (autonomous, semiautonomous, or surgeon-controlled) used for skull base neurosurgical procedures. Cadaveric and human clinical studies were included. Studies with exclusively otorhinolaryngological applications or using robotic microscopes were excluded. RESULTS A total of 561 studies were identified from the initial search, of which 22 were included following full-text review. Transoral robotic surgery (TORS) using the da Vinci Surgical System was the most widely reported system (4 studies) utilized for skull base and pituitary fossa procedures; additionally, it has been reported for resection of sellar masses in 4 patients. Seven cadaveric studies used the da Vinci Surgical System to access the skull base using alternative, non–TORS approaches (e.g., transnasal, transmaxillary, and supraorbital). Five cadaveric studies investigated alternative systems to access the skull base. Six studies investigated the use of robotic endoscope holders. Advantages to robotic applications in skull base neurosurgery included improved lighting and 3D visualization, replication of more traditional gesture-based movements, and the ability for dexterous movements ordinarily constrained by small operative corridors. Limitations included the size and angulation capacity of the robot, lack of drilling components preventing fully robotic procedures, and cost. Robotic endoscope holders may have been particularly advantageous when the use of a surgical assistant or second surgeon was limited. CONCLUSIONS Robotic skull base neurosurgery has been growing in popularity and feasibility, but significant limitations remain. While robotic systems seem to have allowed for greater maneuverability and 3D visualization, their size and lack of neurosurgery-specific tools have continued to prevent widespread adoption into current practice. The next generation of robotic technologies should prioritize overcoming these limitations.

Autonomous Surgical Robotics at Task and Subtask Levels

The revolution of minimally invasive procedures had a significant influence on surgical practice, opening the way to laparoscopic surgery, then evolving into robotics surgery. Teleoperated master-slave robots, such as the da Vinci Surgical System, has become a standard of care during the last few decades, performing over a million procedures per year worldwide. Many believe that the next big step in the evolution of surgery is partial automation, which would ease the cognitive load on the surgeon, making them possible to pay more attention on the critical parts of the intervention. Partial and sequential introduction and increase of autonomous capabilities could provide a safe way towards Surgery 4.0. Unfortunately, autonomy in the given environment, consisting mostly of soft organs, suffers from grave difficulties. In this chapter, the current research directions of subtask automation in surgery are to be presented, introducing the recent advances in motion planning, perception, and human-machine interaction, along with the limitations of the task-level autonomy.

Current Status of Transoral Surgery for Patients With Early-Stage Pharyngeal and Laryngeal Cancers in Japan

As the laryngopharynx is closely related to swallowing, speech, and phonation, it is necessary to consider not only disease control but also a minimally invasive approach for the treatment of laryngopharyngeal cancer. Transoral surgery has been reported to be a minimally invasive method for treating these diseases. Transoral videolaryngoscopic surgery (TOVS) and endoscopic laryngo-pharyngeal surgery (ELPS) have been developed in Japan and recently emerged as treatments for patients with early stage pharyngeal and laryngeal cancers. However, securing an appropriate field of view and a narrow operating space during TOVS or ELPS are critical issues to be resolved for these surgeries. The clinical significance and safety of transoral robotic surgery (TORS) using the da Vinci Surgical System have been widely reported to provide surgeons with increased visualization and magnification, resulting in precise surgical margins and rapid functional recovery. In this context, a multi-institutional clinical study was conducted to evaluate the treatment outcomes of TORS for the treatment of laryngopharyngeal cancer in Japan, and the da Vinci Surgical System for oral robot-assisted surgery for these diseases was approved by the Pharmaceutical Affairs Agency in August 2018. This review provides an overview of the therapeutic effects of TOVS, ELPS, and TORS, with a particular focus on these therapeutic results in Japan.

Preliminary Experiences With Robot-Assisted Choledochal Cyst Excision Using the Da Vinci Surgical System in Children Below the Age of One

The purpose of this study is to introduce our preliminary experiences with using the da Vinci surgical system to treat choledochal cysts in children under 1 year old and discuss the application of this robot-assisted surgery. We retrospectively analyzed all available clinical data of children below the age of 1 who underwent surgery for choledochal cysts using the da Vinci robotic surgical system between January 2015 and December 2020. Data collection mainly included demographic information, imaging data, perioperative details, and postoperative outcomes. Ten patients were included in this study. The average patient age was 8.5 months, and the average weight was 9.11 kg. Half of these patients suffered from abdominal pain, while 30% exhibited vomiting and 10% jaundice. Eight of them were type Ia, and two were Ic. The average operation time among the patients was 219.5 min. None of the 10 patients had to receive a blood transfusion or conversion. The average time of the patients' subsequent fluid diet was 3.28 days, and the solid diet was 3.76 days. Meanwhile, the average length of hospital stay was 7.6 days. All 10 patients recovered and were eventually discharged. We believe that the da Vinci surgical system is a safe and feasible form of treatment for choledochal cysts in children <1 year old.

A Scoping Review of Emerging and Established Surgical Robotic Platforms With Applications in Urologic Surgery

Objectives Since the introduction of the first master–slave robotic platform for surgical procedures, there have been ongoing modifications and development of new platforms, but there is still a paucity of commercially available systems. Our study aims to identify all master–slave robotic surgical platforms currently commercially available or in development around the world with applications in urologic surgery. Methods A scoping literature search was performed using PRISMA methodology to identify all relevant publications in English in PubMed, PubMed Central, and Embase, with additional information being obtained from official company websites. Results Ten robotic platforms with either proven or potential application in urologic surgery were identified: the da Vinci surgical system (Intuitive), Senhance surgical system (Transentrix), Versius Surgical (CMR Ltd), Enos surgical system (Titan Medical), Revo –I (Meere Company), MiroSurge (DLR), Avatera System (Avatera Medical), Hugo Surgical Robot (Medtronic), Ottava (J&J, Ethicon, Areus), and Hinotori (Medicaroid Corporation). Conclusions This review highlights the distinct features of emerging master–slave robotic platforms with applications in urologic surgery. Research and development are now focused on finding wider applications, improving outcomes, increasing availability, and reducing cost. Additional research is required comparing newly developed master–slave robotic platforms with those already well established.

Robotic Dual-Console Distal Pancreatectomy: Could it be Considered a Safe Approach and Surgical Teaching even in Pancreatic Surgery? A Retrospective Observational Study Cohort

Background The study aims to assess the safety and feasibility of the robotic dual-console during a robotic distal pancreatectomy Methods The data of the consecutive patients submitted to RDP from 2012 to 2019 at the Verona University were retrieved from a prospectively maintained database. The patients submitted to RDP were divided into the dual-console platform group (DG) and compared to the standard robotic procedure group (SG). Results In the study period, 102 robotic distal pancreatectomies were performed, of whom 42 patients (41%) belonged to the DG and 60 patients (59%) to the SG. Higher operation time was recorded in the DG compared to the SG (410 vs. 265 min, p < 0.001). The overall conversion rate of the series was 7% (n 7 patients). All the conversions were observed in the SG (p = 0.021). No differences in morbidity or pancreatic fistula rate were recorded (p > 0.05). No mortality events in the 90th postoperative days were reported in this series. Conclusions The robotic dual-console approach for distal pancreatectomy is safe, feasible, and reproducible. The postoperative surgical outcomes are comparable to the standard RDP with the single-console da Vinci Surgical System®. This surgical technique can widely and safely improve the robotic surgical training program.

Robot-assisted thoracoscopic enucleation for a large esophageal leiomyoma: a case report

Background Video-assisted thoracoscopic surgery (VATS) is being used to treat esophageal submucosal tumors (SMTs) all over the world. However, this technique is difficult when the tumor is large and located on the left side wall of the esophagus, within the upper mediastinum. This is because, with VATS, the surgical forceps have a limited range of motion. Robot-assisted thoracoscopic surgery (RATS) using the da Vinci surgical system may be extremely useful for enucleation of esophageal SMTs within the narrow upper mediastinum. Case presentation A female in her thirties experiencing epigastric pain visited our hospital and was diagnosed with a large esophageal leiomyoma within the upper mediastinum. From its size (10 cm), it was judged to have malignant potential. We performed SMT enucleation using RATS with a da Vinci surgical system Xi. This was our second case using this system. The patient was placed in the left lateral position. Four da Vinci trocars (8 mm) were inserted into the 10th, 7th, 5th and 3rd intercostal spaces (ICS), and an assist port was added in the 5th ICS. We opened the superior mediastinal pleura cranially and caudally from the arch of the azygos vein and expanded the superior mediastinum after dividing the azygos vein. We made an incision in the muscular layer of the esophagus and, using a monopolar hook and monopolar scissors, enucleated the esophageal tumor in a protective manner so as not to damage its capsule or mucosa while applying appropriate robot-specific counter traction. We then sewed up the muscularis using 4–0 Vicryl, inserting the endoscope into the thoracic esophagus to substitute for a bougie. In addition, the pleura was sutured using barbed suture. The surgical procedure was straightforward and smooth. The patient was discharged on postoperative day 4 with no surgical complications. The tumor was definitively diagnosed pathologically from paraffin sections as a benign esophageal leiomyoma. Conclusions RATS enables more delicate and precise esophageal SMT enucleation without surgical complications, though various challenges remain to be overcome.

Autonomous pick-and-place using the dVRK

Purpose Robotic-assisted partial nephrectomy (RAPN) is a tissue-preserving approach to treating renal cancer, where ultrasound (US) imaging is used for intra-operative identification of tumour margins and localisation of blood vessels. With the da Vinci Surgical System (Sunnyvale, CA), the US probe is inserted through an auxiliary access port, grasped by the robotic tool and moved over the surface of the kidney. Images from US probe are displayed separately to the surgical site video within the surgical console leaving the surgeon to interpret and co-registers information which is challenging and complicates the procedural workflow. Methods We introduce a novel software architecture to support a hardware soft robotic rail designed to automate intra-operative US acquisition. As a preliminary step towards complete task automation, we automatically grasp the rail and position it on the tissue surface so that the surgeon is then able to manipulate manually the US probe along it. Results A preliminary clinical study, involving five surgeons, was carried out to evaluate the potential performance of the system. Results indicate that the proposed semi-autonomous approach reduced the time needed to complete a US scan compared to manual tele-operation. Conclusion Procedural automation can be an important workflow enhancement functionality in future robotic surgery systems. We have shown a preliminary study on semi-autonomous US imaging, and this could support more efficient data acquisition.

PP445 Mapping The Trend Of The Da Vinci Surgical System Use In China

IntroductionA robotically assisted surgical system, the da Vinci surgical system (DVSS), is a sophisticated surgical platform equipped with immersive 3D visualization and dexterous articulating endoscopic instruments. Surgeons can intuitively control the surgical system to perform delicate surgical tasks. Robotic surgery has gained popularity globally ever since its birth and was approved to market by the China Food and Drug Administration in 2006. This study aims to map the current use of DVSSs in mainland China and the trends from 2009 to 2019.MethodsA full-sample survey of all hospitals equipped with DVSSs was conducted in mainland China, collecting data on hospitals and surgical departments using DVSSs, operation volume, and time of installation. Disease classification was standardized to obtain DVSS use in each department. EXCEL software was used for logging and cleaning the data. The analysis focused on descriptive analysis to map trends of DVSS use in China and present geographical and department distribution.ResultsThe DVSSs installed have grown from seven in 2009 to 135 in 2019. By the end of 2019, twenty-eight provinces in China have been equipped with the DVSSs, among which eighty-seven in the eastern regions, twenty-seven in the central regions, and twenty-one in the western regions. The annual volume of operations grew from 339 in 2009 to 38,991 in 2019, at an annual rate of 60.7 percent. The average workload conducted by a single robot is much higher than that of their counterparts in other countries. The largest share of the volume is in department of urology (48%), followed by general surgery (25%) and thoracic surgery (13%).ConclusionsThe use of DVSSs in China has been growing rapidly and extensively, with certain differences between geographical regions and surgical departments. We need to further explore the factors affecting its use and operation efficiency and to evaluate the effectiveness as well as cost-effectiveness in real-world clinical practice to inform public policies on application of DVSS, for example, license and insurance.