No abstract

No abstract

No abstract

ObjectiveTo detail robotic procedure development and clinical applications for mitral valve, biliary, and gastric reflux operations, and to implement a multispecialty robotic surgery training curriculum for both surgeons and surgical teams. Summary Background DataRemote, accurate telemanipulation of intracavitary instruments by general and cardiac surgeons is now possible. Complex technologic advancements in surgical robotics require well-designed training programs. Moreover, efficient robotic surgical procedures must be developed methodically and safely implemented clinically. MethodsAdvanced training on robotic systems provides surgeon confidence when operating in tiny intracavitary spaces. Three-dimensional vision and articulated instrument control are essential. The authors' two da Vinci robotic systems have been dedicated to procedure development, clinical surgery, and training of surgical specialists. Their center has been the first United States site to train surgeons formally in clinical robotics. ResultsEstablished surgeons and residents have been trained using a defined robotic surgical educational curriculum. Also, 30 multispecialty teams have been trained in robotic mechanics and electronics. Initially, robotic procedures were developed experimentally and are described. In the past year the authors have performed 52 robotic-assisted clinical operations: 18 mitral valve repairs, 20 cholecystectomies, and 14 Nissen fundoplications. These respective operations required 108, 28, and 73 minutes of robotic telemanipulation to complete. Procedure times for the last half of the abdominal operations decreased significantly, as did the knot-tying time in mitral operations. There have been no deaths and few complications. One mitral patient had postoperative bleeding. ConclusionRobotic surgery can be performed safely with excellent results. The authors have developed an effective curriculum for training teams in robotic surgery. After training, surgeons have applied these methods effectively and safely.Surgeons always have sought methods to develop new operations, but many times have been limited by technology. In many instances, initial endoscopic surgical training of senior surgeons and residents alike proceeded along variable pathways without significant prior procedure development or detailed curricula. Early clinical training frequently was at the expense of the best surgical results. Bonchek, 1 Lytle, 2 and Cooley 3 have cautioned surgeons who veer from established techniques with proven results, even if much larger incisions are required.Multispecialty procedure development is very important when any new technology is introduced in surgery. Our trek for developing surgical robotics and training surgeons has been predicated on quality expected from conventional procedures, or "base camps." Progression to each successive level has been followed by technologic "acclimatization" and experience before attempting the last challenge to surgical telemanipulation.

Early results suggest that video-assisted minimally invasive mitral operations can be done safely. These methods may benefit patients through less morbidity, earlier discharge, and lower cost.

No abstract

Over the past 15 years, repair techniques, improved prostheses, retrograde cardioplegia, and enhanced exposure collectitvely have led to impressive advances in mitral valve surgery. Just as minimally invasive coronary surgery appears efficacious, cardiac valve operations using similar techniques are promising. Recently, Kaneko and associates 1 reported videoscopic examination of the mitral valve during a commissurotomy done via a sternotomyo Early this year, port-access mitral replacements were done in Malaysia by the Stanford team using new aortic balloon occlusive technology. On February 26, 1996, Carpentier successfully performed the first video-assisted mitral valve repair through a minithoracotomy during ventriculai fibrillation. 2 On May 26, 1996, our group performed a direct vision "micro-mitral" valve repair with antegrade cardioplegic arrest through a 2.4-inch incision. Two days later we replaced a rheumatic mitral valve using a video-assisted minimally invasive approach, and this case is the subject of this report.The patient was a 43-year-old man with diabetes and long-standing mitral insufficiency that had progressed to class III heart failure and recent-onset atrial fibrillation. Cardiac catheterization showed normal coronary arteries and a 0.45 ventricular ejection fraction. Transthoracic echocardiography showed an immobile posterior leaflet with type III severe mitral insufficiency. Intraoperative transesophageal echocardiography confirmed the transthoracic study. The patient was intubated with a double-lumen endotracheal tube for single lung ventilation and positioned with the right side of the chest elevated 45 degrees and the pelvis nearly flat. A 2-inch incision was made in the midaxillary line over the fifth rib and a small section was removed. A custom retractor was used to provide operative exposure (Snowden-Pencer Inc.). The pericardium was opened just anterior to the phrenic nerve with thoracoscopy scissors. Specialized instruments were used throughout the operation: however, video access was established by means of standard thoracoscopic techniques. A 10 mm thoracoscopic port was placed posterior and cephalad to the main incision, and a three-chip lighted camera (Linvatec Inc.) was inserted to visualize the limited surgical field.Peripheral cardiopulmonary support (28 ° C

In the past decade, robot-assisted surgery has become increasingly used to assist in minimally invasive surgical procedures. In this article we review the evolution of robotic devices, from the first use of an industrial robot for stereotactic biopsies to pioneering work with robots used for hip and prostate surgery, to the development of robotic guidance systems that enabled solo endoscopic surgery, to telemanipulative surgery with master-servant computer-enhanced robotic devices. In addition, we review our early experience with da Vinci Robotic Surgical Systems (Intuitive Surgical, Inc., Mountain View, CA, U.S.A.), which we used to perform robot-assisted laparoscopic cholecystectomies.