Research

16 pages, 4421 KiB

Open AccessArticle

Next in Surgical Data Science: Autonomous Non-Technical Skill Assessment in Minimally Invasive Surgery Training

by Renáta Nagyné Elek and Tamás Haidegger

J. Clin. Med. 2022, 11(24), 7533; https://doi.org/10.3390/jcm11247533 - 19 Dec 2022

Cited by 2 | Viewed by 2167

Background: It is well understood that surgical skills largely define patient outcomes both in Minimally Invasive Surgery (MIS) and Robot-Assisted MIS (RAMIS). Non-technical surgical skills, including stress and distraction resilience, decision-making and situation awareness also contribute significantly. Autonomous, technologically supported objective skill assessment [...] Read more.

Background: It is well understood that surgical skills largely define patient outcomes both in Minimally Invasive Surgery (MIS) and Robot-Assisted MIS (RAMIS). Non-technical surgical skills, including stress and distraction resilience, decision-making and situation awareness also contribute significantly. Autonomous, technologically supported objective skill assessment can be efficient tools to improve patient outcomes without the need to involve expert surgeon reviewers. However, autonomous non-technical skill assessments are unstandardized and open for more research. Recently, Surgical Data Science (SDS) has become able to improve the quality of interventional healthcare with big data and data processing techniques (capture, organization, analysis and modeling of data). SDS techniques can also help to achieve autonomous non-technical surgical skill assessments. Methods: An MIS training experiment is introduced to autonomously assess non-technical skills and to analyse the workload based on sensory data (video image and force) and a self-rating questionnaire (SURG-TLX). A sensorized surgical skill training phantom and adjacent training workflow were designed to simulate a complicated Laparoscopic Cholecystectomy task; the dissection of the cholecyst’s peritonial layer and the safe clip application on the cystic artery in an uncomfortable environment. A total of 20 training sessions were recorded from 7 subjects (3 non-medicals, 2 residents, 1 expert surgeon and 1 expert MIS surgeon). Workload and learning curves were studied via SURG-TLX. For autonomous non-technical skill assessment, video image data with tracked instruments based on Channel and Spatial Reliability Tracker (CSRT) and force data were utilized. An autonomous time series classification was achieved by a Fully Convolutional Neural Network (FCN), where the class labels were provided by SURG-TLX. Results: With unpaired t-tests, significant differences were found between the two groups (medical professionals and control) in certain workload components (mental demands, physical demands, and situational stress,

p < 0.0001

, 95% confidence interval,

p < 0.05

for task complexity). With paired t-tests, the learning curves of the trials were also studied; the task complexity resulted in a significant difference between the first and the second trials. Autonomous non-technical skill classification was based on the FCN by applying the tool trajectories and force data as input. This resulted in a high accuracy (85%) on temporal demands classification based on the z component of the used forces and 75% accuracy for classifying mental demands/situational stress with the x component of the used forces validated with Leave One Out Cross-Validation. Conclusions: Non-technical skills and workload components can be classified autonomously based on measured training data. SDS can be effective via automated non-technical skill assessment. Full article

(This article belongs to the Special Issue Advances in Robot-Assisted Minimally Invasive Surgery)

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10 pages, 26800 KiB

Open AccessArticle

Comparison of the Postoperative Outcomes of the Mini-Flap Bilateral Axillo-Breast Approach (BABA) and Conventional BABA Robot-Assisted Thyroidectomy

by Ik Beom Shin and Dong Sik Bae

J. Clin. Med. 2022, 11(16), 4894; https://doi.org/10.3390/jcm11164894 - 20 Aug 2022

Cited by 3 | Viewed by 1628

Abstract

The bilateral axillo-breast approach (BABA) for robot-assisted thyroidectomy has some advantages over other minimally invasive thyroidectomies. However, some people do not consider this as a minimally invasive thyroidectomy because of the wider surgical skin flap. Thus, we devised mini-flap BABA robot-assisted thyroidectomy and [...] Read more.

The bilateral axillo-breast approach (BABA) for robot-assisted thyroidectomy has some advantages over other minimally invasive thyroidectomies. However, some people do not consider this as a minimally invasive thyroidectomy because of the wider surgical skin flap. Thus, we devised mini-flap BABA robot-assisted thyroidectomy and analyzed the postoperative outcomes. The clinical records of 44 patients undergoing BABA robot-assisted thyroidectomy using a conventional flap or mini-flap were evaluated retrospectively. There were no significant group differences in clinicopathological characteristics. The operating and flap making times were shorter in the mini-flap group (206.18 ± 31.09 vs. 178.90 ± 34.43 min, p = 0.009; 38.85 ± 2.73 vs. 32.21 ± 8.62 min, p = 0.003, respectively). The total drainage amount was smaller in the mini-flap group (196.57 ± 81.40 vs. 150.74 ± 40.80 mL, p = 0.027). The numeric rating scale score and number of analgesics were lower at 2 h postoperatively in the mini-flap group (5.52 ± 0.87 vs. 4.57 ± 1.31, p = 0.006; 0.95 ± 0.22 vs. 0.65 ± 0.49, p = 0.012, respectively). There was no significant group difference in immediate oncological outcomes (p = 1.000). Mini-flap BABA robot-assisted thyroidectomy minimized the surgical flap and improved surgical outcomes. Therefore, it is a form of minimally invasive thyroidectomy. However, long-term follow-up of oncological outcomes is needed. Full article

(This article belongs to the Special Issue Advances in Robot-Assisted Minimally Invasive Surgery)

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9 pages, 1174 KiB

Open AccessArticle

Development and Validation of a Virtual Reality Simulator for Robot-Assisted Minimally Invasive Liver Surgery Training

by Alan Kawarai Lefor, Saúl Alexis Heredia Pérez, Atsushi Shimizu, Hung-Ching Lin, Jan Witowski and Mamoru Mitsuishi

J. Clin. Med. 2022, 11(14), 4145; https://doi.org/10.3390/jcm11144145 - 17 Jul 2022

Cited by 3 | Viewed by 1560

Abstract

The value of kinematic data for skill assessment is being investigated. This is the first virtual reality simulator developed for liver surgery. This simulator was coded in C++ using PhysX and FleX with a novel cutting algorithm and used a patient data-derived model [...] Read more.

The value of kinematic data for skill assessment is being investigated. This is the first virtual reality simulator developed for liver surgery. This simulator was coded in C++ using PhysX and FleX with a novel cutting algorithm and used a patient data-derived model and two instruments functioning as ultrasonic shears. The simulator was evaluated by nine expert surgeons and nine surgical novices. Each participant performed a simulated metastasectomy after training. Kinematic data were collected for the instrument position. Each participant completed a survey. The expert participants had a mean age of 47 years and 9/9 were certified in surgery. Novices had a mean age of 30 years and 0/9 were certified surgeons. The mean path length (novice 0.76 ± 0.20 m vs. expert 0.46 ± 0.16 m, p = 0.008), movements (138 ± 45 vs. 84 ± 32, p = 0.043) and time (174 ± 44 s vs. 102 ± 42 s, p = 0.004) were significantly different for the two participant groups. There were no significant differences in activating the instrument (107 ± 25 vs. 109 ± 53). Participants considered the simulator realistic (6.5/7) (face validity), appropriate for education (5/7) (content validity) with an effective interface (6/7), consistent motion (5/7) and realistic soft tissue behavior (5/7). This study showed that the simulator differentiates between experts and novices. Simulation may be an effective way to obtain kinematic data. Full article

(This article belongs to the Special Issue Advances in Robot-Assisted Minimally Invasive Surgery)

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17 pages, 4086 KiB

Open AccessArticle

Tips and Details for Successful Robotic Myomectomy: Single-Center Experience with the First 125 Cases

by Lei Dou and Yi Zhang

J. Clin. Med. 2022, 11(11), 3221; https://doi.org/10.3390/jcm11113221 - 05 Jun 2022

Cited by 1 | Viewed by 4170

Abstract

With the continuous development of minimally invasive and precise surgical techniques, laparoscopic myomectomy has become a mainstream surgical method due to its aesthetic outcomes and rapid postoperative recovery. However, during laparoscopic myomectomy, clinicians often encounter unfavorable factors, such as limited vision, inaccurate suturing, [...] Read more.

With the continuous development of minimally invasive and precise surgical techniques, laparoscopic myomectomy has become a mainstream surgical method due to its aesthetic outcomes and rapid postoperative recovery. However, during laparoscopic myomectomy, clinicians often encounter unfavorable factors, such as limited vision, inaccurate suturing, difficulty in removing tumors, and susceptibility to fatigue in the operating position. In recent years, robot-assisted surgery has been widely used in gynecology. The advantages of this technique, such as a three-dimensional surgical view, reducing the surgeon’s tremor, and the seven degrees of freedom of the robotic arms, compensate for the defects in laparoscopic surgery. The Department of Gynecology in our hospital has accumulated a wealth of experience since robot-assisted surgery was first carried out in 2017. In this article, the surgical skills of the robotic myomectomy process are described in detail. Full article

(This article belongs to the Special Issue Advances in Robot-Assisted Minimally Invasive Surgery)

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18 pages, 3544 KiB

Open AccessArticle

Toward Optimal Learning of the Gesture in Laparoscopic Surgery: Methodology and Performance

by Marine Cau, Juan Sandoval, Amaël Arguel, Cyril Breque, Nathalie Huet, Jerome Cau and Med Amine Laribi

J. Clin. Med. 2022, 11(5), 1398; https://doi.org/10.3390/jcm11051398 - 03 Mar 2022

Cited by 1 | Viewed by 2015

Abstract

Classical surgical education has to face both a forensic reality and a technical issue: to train a learner in more complex techniques in an increasingly short time. Moreover, surgical training is still based on an empirical hierarchical relationship in which learners must reproduce [...] Read more.

Classical surgical education has to face both a forensic reality and a technical issue: to train a learner in more complex techniques in an increasingly short time. Moreover, surgical training is still based on an empirical hierarchical relationship in which learners must reproduce a sequence of actions in a situation of strong emotional pressure. However, the effectiveness of learning and its quality are linked to the emotional states in which learners find themselves. Among these emotions, epistemic confusion can be found that arises in complex learning situations where there is a cognitive imbalance related to the comprehension of the task, and which results from a rupture between the pre-established patterns of the learner and the new learning task. Although one knows that confusion can have a beneficial or a negative impact on learning, depending on whether it is well regulated or not, the factors that can influence it positively are still poorly understood. Thus, the objective of this experiment is to assess the impact of confusion on the learning of a surgical procedure in an augmented reality context and to determine if this impact varies according to the feedback given to the learners and according to the occurrence of disruptive events. Medical externs were recruited (N = 15) who were required to perform a suturing task on a simulator and whose performance was measured using a Motion Capture (MoCap) system. Even though the statistical analyzes did not allow a conclusion to be reached, the protocol already established makes it possible to consider a longer-term study that will allow (by increasing the number of sessions and the number of participants) more significant results to be obtained in order to develop new surgical learning protocols. This preliminary study opens a new field of research on the influence of epistemic emotions, and more particularly of confusion, which is likely to upset traditional surgical teaching, and is based on negative conditioning and strong emotions with negative valence as well as stress and coercion. Full article

(This article belongs to the Special Issue Advances in Robot-Assisted Minimally Invasive Surgery)

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Review

Jump to: Research, Other

14 pages, 3840 KiB

Open AccessReview

Robot-Assisted Tubal Reanastomosis after Sterilization: A Choice for Family Planning

by Arwa Salehjawich, Veronika Günther, Zino Ruchay, Mazhar Salim Al Zoubi, Juhi Dhanawat, Nicolai Maass, Johannes Ackermann, Julian Pape and Ibrahim Alkatout

J. Clin. Med. 2022, 11(15), 4385; https://doi.org/10.3390/jcm11154385 - 28 Jul 2022

Cited by 1 | Viewed by 1997

Abstract

A variety of procedures have been used for family planning. One of these is sterilization surgery, which can be reversed by a tubal reanastomosis. In the present report, we compare Robot-assisted tubal reanastomosis sterilization with other methods of family planning and discuss factors [...] Read more.

A variety of procedures have been used for family planning. One of these is sterilization surgery, which can be reversed by a tubal reanastomosis. In the present report, we compare Robot-assisted tubal reanastomosis sterilization with other methods of family planning and discuss factors related to the choice of the approach. The keywords used for the electronic search in PubMed were family planning, sterilization, Robot-assisted, tubal reanastomosis, depression, and regret. The decision in favor of or against sterilization surgery has been a sensitive issue for several years. Robot-assisted technology is a modern and precise approach. It has contributed to the flexibility of the decision between sterilization and its reversal through tubal reanastomosis, as well as enhanced the success rate of the surgery. Based on our analysis of the published literature, we believe that Robot-assisted tubal anastomosis is the optimum approach. However, to ensure the quality of health care, the surgeon must be well trained, well versed with the anatomy of the fallopian tubes, and thoroughly informed on the psychological impact of family planning. Full article

(This article belongs to the Special Issue Advances in Robot-Assisted Minimally Invasive Surgery)

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20 pages, 1601 KiB

Open AccessReview

Assessment of the Versius Robotic Surgical System in Minimal Access Surgery: A Systematic Review

by Ibrahim Alkatout, Hamid Salehiniya and Leila Allahqoli

J. Clin. Med. 2022, 11(13), 3754; https://doi.org/10.3390/jcm11133754 - 28 Jun 2022

Cited by 15 | Viewed by 2986

Abstract

Background: Despite the superiority of minimal access surgery (MAS) over open surgery, MAS is difficult to perform and has a demanding learning curve. Robot-assisted surgery is an advanced form of MAS. The Versius^® surgical robot system was developed with the aim of [...] Read more.

Background: Despite the superiority of minimal access surgery (MAS) over open surgery, MAS is difficult to perform and has a demanding learning curve. Robot-assisted surgery is an advanced form of MAS. The Versius^® surgical robot system was developed with the aim of overcoming some of the challenges associated with existing surgical robots. The present study was designed to investigate the feasibility, clinical safety, and effectiveness of the Versius system in MAS. Materials and Methods: A comprehensive search was carried out in the Medline, Web of Science Core Collection (Indexes = SCI-EXPANDED, SSCI, A & HCI Timespan), and Scopus databases for articles published until February 2022. The keywords used were Versius robot, visceral, colorectal, gynecology, and urologic surgeries. Articles on the use of the Versius robot in minimal access surgery (MAS) were included in the review. Results: Seventeen articles were reviewed for the study. The investigation comprised a total of 328 patients who had been operated on with this robot system, of which 48.3%, 14.2%, and 37.5% underwent colorectal, visceral, and gynecological procedures, respectively. Postoperative and major complications within 30 days varied from 7.4% to 39%. No major complications and no readmissions or reoperations were reported in visceral and gynecological surgeries. Readmission and reoperation rates in colorectal surgeries were 0–9%. Some procedures required conversion to conventional laparoscopic surgery (CLS) or open surgery, and all procedures were completed successfully. Based on the studies reviewed in the present report, we conclude that the Versius robot can be used safely and effectively in MAS. Conclusions: A review of the published literature revealed that the Versius system is safe and effective in minimal access surgery. However, the data should be viewed with caution until randomized controlled trials (RCTs) have been performed. Studies on the use of this robotic system in oncological surgery must include survival as one of the addressed outcomes. Full article

(This article belongs to the Special Issue Advances in Robot-Assisted Minimally Invasive Surgery)

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24 pages, 1944 KiB

Open AccessReview

Laparoscopic and Robot-Assisted Hepatic Surgery: An Historical Review

by Atsushi Shimizu, Miwa Ito and Alan Kawarai Lefor

J. Clin. Med. 2022, 11(12), 3254; https://doi.org/10.3390/jcm11123254 - 07 Jun 2022

Cited by 5 | Viewed by 1876

Abstract

Hepatic surgery is a rapidly expanding component of abdominal surgery and is performed for a wide range of indications. The introduction of laparoscopic cholecystectomy in 1987 was a major change in abdominal surgery. Laparoscopic surgery was widely and rapidly adopted throughout the world [...] Read more.

Hepatic surgery is a rapidly expanding component of abdominal surgery and is performed for a wide range of indications. The introduction of laparoscopic cholecystectomy in 1987 was a major change in abdominal surgery. Laparoscopic surgery was widely and rapidly adopted throughout the world for cholecystectomy initially and then applied to a variety of other procedures. Laparoscopic surgery became regularly applied to hepatic surgery, including segmental and major resections as well as organ donation. Many operations progressed from open surgery to laparoscopy to robot-assisted surgery, including colon resection, pancreatectomy, splenectomy thyroidectomy, adrenalectomy, prostatectomy, gastrectomy, and others. It is difficult to prove a data-based benefit using robot-assisted surgery, although laparoscopic and robot-assisted surgery of the liver are not inferior regarding major outcomes. When laparoscopic surgery initially became popular, many had concerns about its use to treat malignancies. Robot-assisted surgery is being used to treat a variety of benign and malignant conditions, and studies have shown no deterioration in outcomes. Robot-assisted surgery for the treatment of malignancies has become accepted and is now being used at more centers. The outcomes after robot-assisted surgery depend on its use at specialized centers, the surgeon’s personal experience backed up by extensive training and maintenance of international registries. Robot-assisted hepatic surgery has been shown to be associated with slightly less intraoperative blood loss and shorter hospital lengths of stay compared to open surgery. Oncologic outcomes have been maintained, and some studies show higher rates of R0 resections. Patients who need surgery for liver lesions should identify a surgeon they trust and should not be concerned with the specific operative approach used. The growth of robot-assisted surgery of the liver has occurred in a stepwise approach which is very different from the frenzy that was seen with the introduction of laparoscopic cholecystectomy. This approach allowed the identification of areas for improvement, many of which are at the nexus of engineering and medicine. Further improvements in robot-assisted surgery depend on the combined efforts of engineers and surgeons. Full article

(This article belongs to the Special Issue Advances in Robot-Assisted Minimally Invasive Surgery)

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18 pages, 1093 KiB

Open AccessReview

Robot-Assisted Minimally Invasive Breast Surgery: Recent Evidence with Comparative Clinical Outcomes

by Kuo Chen, Jin Zhang, Narasimha M. Beeraka, Mikhail Y. Sinelnikov, Xinliang Zhang, Yu Cao and Pengwei Lu

J. Clin. Med. 2022, 11(7), 1827; https://doi.org/10.3390/jcm11071827 - 25 Mar 2022

Cited by 21 | Viewed by 4093

Abstract

In recent times, robot-assisted surgery has been prominently gaining pace to minimize overall postsurgical complications with minimal traumatization, due to technical advancements in telerobotics and ergonomics. The aim of this review is to explore the efficiency of robot-assisted systems for executing breast surgeries, [...] Read more.

In recent times, robot-assisted surgery has been prominently gaining pace to minimize overall postsurgical complications with minimal traumatization, due to technical advancements in telerobotics and ergonomics. The aim of this review is to explore the efficiency of robot-assisted systems for executing breast surgeries, including microsurgeries, direct-to-implant breast reconstruction, deep inferior epigastric perforators-based surgery, latissimus dorsi breast reconstruction, and nipple-sparing mastectomy. Robot-assisted surgery systems are efficient due to 3D-based visualization, dexterity, and range of motion while executing breast surgery. The review describes the comparative efficiency of robot-assisted surgery in relation to conventional or open surgery, in terms of clinical outcomes, morbidity rates, and overall postsurgical complication rates. Potential cost-effective barriers and technical skills were also delineated as the major limitations associated with these systems in the clinical sector. Furthermore, instrument articulation of robot-assisted surgical systems (for example, da Vinci systems) can enable high accuracy and precision surgery due to its promising ability to mitigate tremors at the time of surgery, and shortened learning curve, making it more beneficial than other open surgery procedures. Full article

(This article belongs to the Special Issue Advances in Robot-Assisted Minimally Invasive Surgery)

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14 pages, 702 KiB

Open AccessReview

Current Status of Robot-Assisted Revisional Bariatric Surgery

by Carolina Vanetta, Nicolás H. Dreifuss, Francisco Schlottmann, Alberto Mangano, Antonio Cubisino, Valentina Valle, Carolina Baz, Francesco M. Bianco, Chandra Hassan, Antonio Gangemi and Mario A. Masrur

J. Clin. Med. 2022, 11(7), 1820; https://doi.org/10.3390/jcm11071820 - 25 Mar 2022

Cited by 7 | Viewed by 3139

Abstract

Bariatric surgery has been demonstrated to be effective in achieving significant weight loss and remission of obesity-related comorbidities. However, a percentage of patients fail to lose enough weight, regain weight, or experience postoperative complications, requiring additional interventions. Revisional bariatric surgeries (RBS) involve the [...] Read more.

Bariatric surgery has been demonstrated to be effective in achieving significant weight loss and remission of obesity-related comorbidities. However, a percentage of patients fail to lose enough weight, regain weight, or experience postoperative complications, requiring additional interventions. Revisional bariatric surgeries (RBS) involve the wide spectrum of procedures that aim to treat complications of the index operation or achieve further weight loss. These are technically challenging procedures due to adhesions of the internal organs, reduced working space, and a distorted anatomy. Indications, timing, and type of operation for RBS are not standardized, and there is no consensus on the best surgical approach. Some authors claim a robotic platform could be advantageous in these types of procedures that are performed in reduced, deep operating fields, or those requiring precision and accuracy. This review examines the most current and representative literature on the outcomes of robot-assisted RBS. Included studies demonstrate the safety and feasibility of the robotic approach for RBS. However, long operative times and high costs remain major drawbacks of the device. Finally, if we consider that many centers have not yet completed the learning curve for robot-assisted RBS, the potential for improved outcomes seems promising. Full article

(This article belongs to the Special Issue Advances in Robot-Assisted Minimally Invasive Surgery)

Other

Jump to: Research, Review

8 pages, 30733 KiB

Open AccessCase Report

Robot-Assisted Autonomous Reduction of a Displaced Pelvic Fracture: A Case Report and Brief Literature Review

by Yufeng Ge, Chunpeng Zhao, Yu Wang and Xinbao Wu

J. Clin. Med. 2022, 11(6), 1598; https://doi.org/10.3390/jcm11061598 - 14 Mar 2022

Cited by 15 | Viewed by 2671

Abstract

Displaced pelvic fracture is among the most complicated fractures in traumatic orthopedics, with high mortality and morbidity. Reduction is considered a complex procedure as well as a key part in surgical treatment. However, few robotic techniques have been employed in the reduction of [...] Read more.

Displaced pelvic fracture is among the most complicated fractures in traumatic orthopedics, with high mortality and morbidity. Reduction is considered a complex procedure as well as a key part in surgical treatment. However, few robotic techniques have been employed in the reduction of pelvic fracture, despite the rapid advancement of technologies. Recently, we designed a robot surgery system specialized in the autonomous reduction of displaced pelvic fracture and applied it in the true patient for the first time. In this paper, we report its successful clinical debut in the surgery of a displaced pelvic fracture. Total surgery time was 110 min and an anatomic reduction was achieved. We then present a brief overview of the literature about reduction techniques in pelvic fracture and introduce related principles involved in our robot-assisted reduction system. Full article

(This article belongs to the Special Issue Advances in Robot-Assisted Minimally Invasive Surgery)

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