Telemicrosurgery: Robot Assisted Microsurgery

Telemicrosurgery: robot-assisted microsurgery

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Editorial Reviews

This allows for the addition of optical magnification which defines conventional microsurgery to robotic instrument arms to allow the microsurgeon to perform complex microsurgical procedures. There are several possible applications for this platform in various microsurgical disciplines.

Since , basic skills training courses have been organized by the Robotic Assisted Microsurgical and Endoscopic Society. These basic courses are performed on training models in five levels of increasing complexity. This paper reviews the current state of the art in robotically asisted microsurgical training. Developed in the s, microsurgery is a surgical technique using optical magnification that allows the microsurgeon to perform delicate movements which are difficult or impossible using the naked eye.

Over the last few years, microsurgery has seen two major technical advances: The latter, telemicrosurgery or robotically assisted microsurgery can be defined as the technique of microsurgery that uses robotic telemanipulators to scale down surgical gestures or movements. The da Vinci robot Intuitive Surgical Inc. RAMSES not only aims to promote microsurgery with robotic manipulators, but also aims to develop a new concept: It combines the properties of microsurgery, endoscopic surgery, and telesurgery. This would not only allow magnification of the view of the operating field, but also enable microsurgeon to scale down the gestures or movements of the operator's hands, while taking a minimally invasive approach.

The purpose of this paper is to describe the models used for training, evaluation methods, and the organization and proceedings of basic and advanced telemicrosurgery training. The only surgical telemanipulator currently available on the market is the da Vinci robot Intuitive Surgical Inc. It consists of three components: The mobile cart contains four articulated robotic arms, three of which carry surgical instruments and a fourth arm that manipulates the digital stereoscopic camera to visualize the surgical field.

Each of these arms has multiple joints providing three-dimensional movement of the surgical instruments and optics. The tools available vary: The fourth arm, which controls the optics, has a stereoscopic, high definition, endoscopic camera. The stereoscopic camera lens comprises a video imaging column similar to that used in conventional laparoscopy or arthroscopy and two light sources and dual stereoscopic cameras for three-dimensional vision with progressive magnification up to 12 to 15 times.

The surgeons' console is equipped with an optical viewing system, two telemanipulation handles, and five pedals. The optical viewing system, called the stereo viewer, offers a three-dimensional view of the operating field and displays text messages and icons that reflect the status of the system in real time.

The two telemanipulation handles allow remote manipulation of the four articulated robotic arms. In its latest version, the da Vinci SI, the robot is equipped with 2 surgeon consoles to allow for the simultaneous use with two operators: In this mode, the 3 robotic arms can be utilized at the same time by the two operators. The robot da Vinci SI contains three parts from right to left: Five properties of the da Vinci robot are essential in telemicrosurgery. The optical magnification of the operating field is obtained by the optical and digital magnification of the stereoscopic camera.

The suppression of physiological tremor improves the quality of surgical movements. The scaling down of surgical movements improves accuracy by reducing the surgeon's movements by a factor of 3 position "fine" or 5 position "extra-fine". The ergonomic design of the surgeons' console is very useful in microsurgery because it improves the comfort of the surgical movements by simplifying the motion.

The possibility of minimally invasive surgery allows the microsurgeon to work in unique operative fields with minimal cutaneous incisions. Robotic telemanipulators have often been criticized for not having tactile feedback. In reality, it has been clearly demonstrated that force or tactile feedback is not absolutely necessary in microsurgery: Successful microsurgery with suture-assisted microsurgical robots has already been reported [ 5 ].

In addition, a new robotic platform, the Amadeus telemanipulator Titan , that will be available soon, will be equipped with tactile feedback. It is not difficult to imagine that, in the future, there will be a robot able to replicate microsurgical maneuvers with tactile feedback force, possibly enabling endoscopic supermicrosurgery [ 1 ]. Among the models currently available in conventional microsurgery, there are nonliving non-biological models latex, silicone, Gore-Tex, PracticeRat , nonliving biological models artery of the chicken wing, pig's feet, placenta and living models mouse, rat, rabbit [ 6 , 7 ].

The ideal model would meet the following specifications: No model perfectly fulfills all these specifications and full education in telemicrosurgery must have several levels of increasing complexity, the ability to address technical challenges, and applicability to varying microsurgical procedures. The first level is to become familiar with the robot and master the basic skills of telemicrosurgery.

This can be done either by means of an analog simulator such as plastic rings Fig. Several simulators are available on the market: Mimic, Ross [ 9 ], dV-Trainer [ 10 ], and da Vinci skills simulator [ 11 ]. The virtual simulators assess students' performances in terms of time to complete the exercise, gesture accuracy, missed targets, instrument collision, drops, etc.

This is one reason why virtual simulators allow for highly efficient self-teaching Fig. Installation of a robot da Vinci SI for level 1 training. Plastic rings must be manipulated and moved from one display stand to the other. DaVinci robot-assisted surgery for colorectal cancer. In this interesting lecture, Professor Yoon Ah Park presents the application of the DaVinci robot system to colorectal laparoscopic surgery presenting the actual benefits and unsolved problems using the robot.

Robot-assisted thoracoscopic right superior lobectomy with conversion for controlled bleeding: As the technique and the indications of robotic video-assisted lung resections have evolved, surgeons have had to face numerous pitfalls. One in particular is the vascular tear, which urge the operator to convert to thoracotomy. The decision as to when and how to convert to thoracotomy is always difficult to make. This video illustrates a complex case of robotic right upper lobectomy which required thoracotomy for controlled bleeding. This is the case of a year-old woman with a past medical history of severe chronic obstructive pulmonary disease, active smoking, alcoholic liver cirrhosis, but no history of tuberculosis.

She presented with a 3-month history of a right upper lobar mass detected on chest X-ray which evolved despite antibiotic treatment. Work-up including a PET-scan evoked a suspicion of malignancy. While finishing the lobectomy, we had to face a difficult dissection of the posterior part of the oblique fissure with a tricky control of the dorsal artery.

Trying to open the fissure with the endostapler, we tore the arterial branch and applied an immediate control by means of a double Cadiere grasper. When bleeding was finally controlled, we decided to convert for safety reasons. We proceeded without undocking the last robotic arm, clamping the artery until control was achieved using thoracotomy instruments.

It allowed us to manage this situation with no rush and stress. There are two types of bleeding: In our experience of RATS lobectomy and by reviewing our complications, we feel that there are several advantages to this technique: Secondly, passive locking of the robotic arm provides sufficient time for the surgical team to prepare conversion.

Full handsewn robotic Roux-en-Y gastric bypass: This video presents a live demonstration of a robotic Roux-en-Y gastric bypass during which the gastrojejunal anastomosis was fully handsewn and performed taking advantage of the stability and wide range of motion offered by the robotic surgery platform.

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Middle lobectomy for a typical carcinoid tumor using 4 robotic arms. We present the case of a year-old woman with a typical carcinoid tumor of the middle lobe of the lung. Bronchoscopy was carried out. A tumor lying in the deep segment of the middle lobe bronchus was identified by biopsy as a typical carcinoid tumor.

We decided to perform middle lobectomy using a four-arm robotic assistance as it allows for a minimally invasive surgery. The patient is intubated with a double lumen tracheal tube. The chapters will explain the training in telemicrosurgery and then propose some experimental paradigms.

The first clinical applications for various specialties will be explored. In closing, potential future applications will be discussed. Enter your mobile number or email address below and we'll send you a link to download the free Kindle App.

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