ENDOSCOPIC SURGERY DISADVANTAGES

UNNATURAL OPERATIVE FEEL 2-D VISION, HANDS AND

INSTRUMENTS MISALIGNED

LIMITED DEXTERITY INSIDE PATIENTS HANDS/WRIST OUTSIDE PATIENT FIXED INSTRUMENTS TIPS INSIDE PATIENT LONG INSTRUMENTS, INVERTED MOVEMENT ONLY 4 DOF + GRIP

COMPUTER-ENHANCED SURGERY

INCREASED DEXTERITY AND PRECISION (6 DOF + GRIP)

IMPROVED INTRA-CAVITARY RANGE OF MOTION

VISUAL IMMERSION

INTUITIVE MOTION (ANTHROPOMORPHIC

CONCEPT)

SCALING

FILTERING

TELESURGICAL PERFORMANCE ENHANCEMENT OF ENDOSCOPIC SURGICAL TECHNIQUE THROUGH:

BASIC ORGANIZATIONAL CRITERIA

STANDARDIZATION OF THE SURGICAL PROCEDURES INSTALLATION OF ROBOTIC SYSTEM AND PLANING THE DISPOSITION OF THE OPERATING ROOM TRAINING OF SURGICAL TEAM ORGANIZATION OF THE WARD QUALITY CONTROL

STANDARDIZATION OF THE SURGICAL PROCEDURES

IT IS NECESSARY TO PERFORM IN A SAFE IT IS NECESSARY TO PERFORM IN A SAFE

AND STRAIGHTFORWARD MANNER AN AND STRAIGHTFORWARD MANNER AN

EXTREMELY ADVANCED AND INNOVATIVE EXTREMELY ADVANCED AND INNOVATIVE

MODALITY LIKE ROBOTIC SURGERY, MODALITY LIKE ROBOTIC SURGERY,

WHERE THE DETAILS TO ATTEND TO ARE A GREAT WHERE THE DETAILS TO ATTEND TO ARE A GREAT

MANY.MANY.

TRAINING OF THE SURGICAL TEAM

SCRUB NURSES TECHNICIANS SURGEONS ANESTHESIOLOGIST

TRAINING OF THE SURGICAL TEAM

ROOM PERSONNEL

(SCRUB NURSES, TECHNICIANS)

IT ALLOW THE CREATION OF A TEAM ABLE TO ACTIVATE IT ALLOW THE CREATION OF A TEAM ABLE TO ACTIVATE AND MAINTAIN THE ENTIRE OPERATIVE SYSTEM, TAKE AND MAINTAIN THE ENTIRE OPERATIVE SYSTEM, TAKE CHARGE AND HANDLING ALL MATERIALS AND CHARGE AND HANDLING ALL MATERIALS AND INSTRUMENTSINSTRUMENTS

APPROXIMATELY 15 DAYS ARE NECESSARY TO APPROXIMATELY 15 DAYS ARE NECESSARY TO COMPLETE ADEQUATE TRAINING OF PERSONNELCOMPLETE ADEQUATE TRAINING OF PERSONNEL

GIULIANOTTI, OSP. ITAL. CHIR., 2001GIULIANOTTI, OSP. ITAL. CHIR., 2001

TRAINING OF THE SURGICAL TEAM

ROOM PERSONNEL SETUP OF ROBOTIC SYSTEM

• Connection of the console to the robotic cart Connection of the console to the robotic cart electric cables electric cables and optic fibersand optic fibers• System switch-onSystem switch-on• Self-testSelf-test• Draping of the robotic arms with insertion of Draping of the robotic arms with insertion of electronic electronic microcircuit platesmicrocircuit plates• Fixing of mechanical supports for trocars on the Fixing of mechanical supports for trocars on the robotic armsrobotic arms

SETUP OF OPTIC SYSTEM ON THE CONSOLE• Frontal or inclined position of the scope (0° - 30°)Frontal or inclined position of the scope (0° - 30°)• White balancingWhite balancing• Setting of the 2-D or 3-D visionSetting of the 2-D or 3-D vision• Vision centering for the monitor of the console Vision centering for the monitor of the console

TRAINING OF THE SURGICAL TEAM

ASSISTANCE ON THE SURGICAL

FIELD

INITIAL PHASE OF THE PROCEDURE

• Patient positioningPatient positioning• Induction of pneumoperitoneumInduction of pneumoperitoneum• Placement of trocarsPlacement of trocars• Initial phase of surgical intervention Initial phase of surgical intervention

(conventional VL)(conventional VL)• Robot cart positioningRobot cart positioning• Introduction/extraction of the robotic surgical Introduction/extraction of the robotic surgical

instrumentsinstruments

TRAINING OF THE SURGICAL TEAM

ASSISTANCE ON THE SURGICAL FIELD

SURGICAL PROCEDURESURGICAL PROCEDURE Placement of trocarsPlacement of trocars Divarication and exposure of operative fieldDivarication and exposure of operative field Introduction of materials in operative field (stitches, Introduction of materials in operative field (stitches,

needles, gauzes, needles, gauzes,

prostheses, endobags)prostheses, endobags)

Use of accessory instruments (clips, staplers, loops)Use of accessory instruments (clips, staplers, loops)

TRAINING OF THE SURGICAL TEAM

ASSISTANCE ON THE SURGICAL

FIELD

FINAL PHASE OF THE SURGICAL PROCEDUREFINAL PHASE OF THE SURGICAL PROCEDURE

• Extraction of operative specimens• Exploration of operative field• Introduction of drain tube• Extraction of the trocars• Desufflaction• Removal of robotic station from patient• First assistance in case of immediate conversion

QUALITY CONTROL

EVALUATION MUST BE CRITICAL AND AIMED EVALUATION MUST BE CRITICAL AND AIMED AT AT INCREASING EFFICENCY, OPTIMIZING INCREASING EFFICENCY, OPTIMIZING AVAILABLE AVAILABLE RESOURCES AND POSSIBLY LOWERING RESOURCES AND POSSIBLY LOWERING COSTSCOSTS

THE MOST SIGNIFICANT INDICATORS ARE: THE MOST SIGNIFICANT INDICATORS ARE: - OPERATIVE TIME- OPERATIVE TIME - RATE OF CONVERSION - RATE OF CONVERSION - MORBIDITY - MORBIDITY - LENGTH OF HOSPITAL STAY- LENGTH OF HOSPITAL STAY

ROBOTIC SURGERY CENTERROBOTIC SURGERY CENTER

CLINICAL PRACTICE CLINICAL PRACTICE

DIDACTIC ACTIVITY DIDACTIC ACTIVITY

RESEARCHRESEARCH

LEARNING CURVESURGEON’S FAMILIARITIATION WITH FOLLOWING ASPECTS:SURGEON’S FAMILIARITIATION WITH FOLLOWING ASPECTS:

BINOCULAR AND THREE-DIMENSIONAL VISIONBINOCULAR AND THREE-DIMENSIONAL VISION

RESTRICTED OPERATIVE FIELDRESTRICTED OPERATIVE FIELD

THE HANDLING OF JOYSTICKSTHE HANDLING OF JOYSTICKS

ROBOTIC SURCICAL INSTRUMENTSROBOTIC SURCICAL INSTRUMENTS

MOVEMENTS OF ROBOTIC ARMS AND OF SURCICAL MOVEMENTS OF ROBOTIC ARMS AND OF SURCICAL

INSTRUMENTS INSTRUMENTS (CONPUTERED TREMOR REDUCTION, WRISTED INSTRUMENTS)

ABSENCE OF TACTILE FEEDBACKABSENCE OF TACTILE FEEDBACK

LEARNING CURVE

1.1.THEORETICAL PHASETHEORETICAL PHASE

2.2.TRAINING AT THE CONSOLE (MECHANICAL OR ANIMALS TRAINING AT THE CONSOLE (MECHANICAL OR ANIMALS

MODELS)MODELS)

3.3.KNOWLEDGE OF THE TECHNICAL ASPECTS OF THE KNOWLEDGE OF THE TECHNICAL ASPECTS OF THE

ROBOTIC SYSTEM, OF PROCEDURES FOR INSTALLING THE ROBOTIC SYSTEM, OF PROCEDURES FOR INSTALLING THE

ROBOT ON OPERATING FIELD, OF HANDLING OF ROBOT ON OPERATING FIELD, OF HANDLING OF

SURGICAL INSTRUMENTSSURGICAL INSTRUMENTS

4.4.CLINICAL APPLICATION (VL COLECISTECTOMY WITH CLINICAL APPLICATION (VL COLECISTECTOMY WITH

TUTORING)TUTORING)

””20 PROCEDURES ARE NECESSARY TO COMPLETE THE LEARNING 20 PROCEDURES ARE NECESSARY TO COMPLETE THE LEARNING CURVE FOR THIS PROCEDURE”CURVE FOR THIS PROCEDURE”

FIRTS 20 FIRTS 20 PATIENTSPATIENTS

38 38 PATIENTSPATIENTS

MEDIAN MEDIAN OPERATIVE OPERATIVE TIME:TIME: 103.5 min103.5 min 75.2 min75.2 min

RANGERANGE (50 – 210)(50 – 210) (30 – (30 –

120)120)

T Student p = 0.002

LEARNING CURVE IN ROBOTIC LEARNING CURVE IN ROBOTIC COLECISTECTOMYCOLECISTECTOMY

GIULIANOTTI, 2001GIULIANOTTI, 2001

HANCE J ET AL: J MEDICAL ROBOTICS AND COMPUTER ASSISTED SURGERY, 2005 HANCE J ET AL: J MEDICAL ROBOTICS AND COMPUTER ASSISTED SURGERY, 2005

CRITERIA FOR EVALUATING ROBOTIC LEARNING CURVE

MAIN PROBLEMSMAIN PROBLEMS

STANDARDISATION OF PATIENTSSTANDARDISATION OF PATIENTS

LACK OF METHODS TO OBJECTIVELY ASSESS PERFORMANCELACK OF METHODS TO OBJECTIVELY ASSESS PERFORMANCE

THE MAJORITY OF STUDIES HAVE FOCUSED UPON DRY LAB THE MAJORITY OF STUDIES HAVE FOCUSED UPON DRY LAB

EXPERIMENTS EXPERIMENTS HANCE J ET AL: J MEDICAL ROBOTICS AND COMPUTER ASSISTED SURGERY, 2005 HANCE J ET AL: J MEDICAL ROBOTICS AND COMPUTER ASSISTED SURGERY, 2005

CRITERIA FOR EVALUATING ROBOTIC LEARNING CURVE

MAIN QUESTIONSMAIN QUESTIONS

“ “ DOES THE ROBOTIC LEARNING CURVE PLATEAU?”DOES THE ROBOTIC LEARNING CURVE PLATEAU?”ANDAND

“ “DOES PREVIOUS LAPAROSCOPIC EXPERIENCE LEAD TO DOES PREVIOUS LAPAROSCOPIC EXPERIENCE LEAD TO FASTER ACQUISITION OF TELEROBOTIC SKILLS?”FASTER ACQUISITION OF TELEROBOTIC SKILLS?”

HANCE J ET AL: J MEDICAL ROBOTICS AND COMPUTER ASSISTED SURGERY, 2005

METHODSMETHODS

13 SURGEONS COMPLETED FIVE SYNTHETIC SMALL BOWEL ANASTOMOSES USING THE DA VINCI SYSTEM

OBJECTIVE STRUCTURED ASSESMENT OF TECHNICAL SKILLS (OSATS) ALLOWED QUALITATIVE ANALYSIS

THE API (APPLICATION PROGRAMMING INTERFACE) SOFTWARE USED TO RETRIEVE REAL-TIME ROBOTIC SIGNAL DATA OF TIME, PATH LENGTH AND NUMBER OF MOVEMENTS (P VALUE < 0.05 WAS CONSIDERED SIGNIFICANT)

HERNANDEZ ET AL: SURG ENDOSC, 2004HERNANDEZ ET AL: SURG ENDOSC, 2004

““QUALITATIVE AND QUANTITATIVE ANALYSIS OF QUALITATIVE AND QUANTITATIVE ANALYSIS OF THE LEARNING CURVE OF A SIMULATED SURGICAL THE LEARNING CURVE OF A SIMULATED SURGICAL

TASK ON THE DA VINCI SYSTEM”TASK ON THE DA VINCI SYSTEM”

RESULTSRESULTS

HERNANDEZ ET AL: SURG ENDOSC, 2004

““QUALITATIVE AND QUANTITATIVE ANALYSIS OF QUALITATIVE AND QUANTITATIVE ANALYSIS OF THE LEARNING CURVE OF A SIMULATED SURGICAL THE LEARNING CURVE OF A SIMULATED SURGICAL

TASK ON THE DA VINCI SYSTEM”TASK ON THE DA VINCI SYSTEM”

FIRST ATTEMPFIRST ATTEMP FIFTH FIFTH ATTEMPATTEMP

pp

OSATS GLOBAL SCORE POINTSOSATS GLOBAL SCORE POINTS 18.618.6 26 0.02TIME (SEC.)TIME (SEC.) 3507 3507 2287 0.008 TOTAL NUMBER OF TOTAL NUMBER OF MOVEMENTSMOVEMENTS 2411 2411

1387 0.01

TOTAL PATH LENGTH (CM)TOTAL PATH LENGTH (CM) 21,63021,630

13,941 0.01

““ROBOTIC SURGERY: IDENTIFYING THE LEARNING ROBOTIC SURGERY: IDENTIFYING THE LEARNING CURVE THROUGH OBJECTIVE MEASUREMENT OF CURVE THROUGH OBJECTIVE MEASUREMENT OF

SKILL”SKILL”CHANG L ET AL: SURG ENDOSC, 2003CHANG L ET AL: SURG ENDOSC, 2003

METHODS

8 SURGEONS PERFORMED INTACORPOREAL KNOT TYING TASKS BEFORE 8 SURGEONS PERFORMED INTACORPOREAL KNOT TYING TASKS BEFORE

AND AND

AFTER 3 WEEK SURGICAL ROBOTIC TRAININGAFTER 3 WEEK SURGICAL ROBOTIC TRAINING

THESE PERFORMANCE WERE COMPARED TO THEIR LAPAROSCOPIC THESE PERFORMANCE WERE COMPARED TO THEIR LAPAROSCOPIC

KNOTS AND ANALYZED TO DETERMINE AND DEFINE SKILL KNOTS AND ANALYZED TO DETERMINE AND DEFINE SKILL

IMPROVEMENT IMPROVEMENT

““ROBOTIC SURGERY: IDENTIFYING THE LEARNING CURVE ROBOTIC SURGERY: IDENTIFYING THE LEARNING CURVE THROUGH OBJECTIVE MEASUREMENT OF SKILL”THROUGH OBJECTIVE MEASUREMENT OF SKILL”

CHANG L ET AL: SURG ENDOSC, 2003CHANG L ET AL: SURG ENDOSC, 2003

RESULTSRESULTS

LAPAROSCOPY ROBOTIC SURGERY AFTER 4-6 HOURS OF LAPAROSCOPY ROBOTIC SURGERY AFTER 4-6 HOURS OF

ROBOTIC TRAINIG ROBOTIC TRAINIG

TIME (SEC.) TIME (SEC.) 140 (M.C.: 77) 390 (M.C.: 40) 139 140 (M.C.: 77) 390 (M.C.: 40) 139 (M.C.: 71)(M.C.: 71)

““LEARNING CURVE MAY PLATEAU SOONER FOR ROBOTIC LEARNING CURVE MAY PLATEAU SOONER FOR ROBOTIC MANIPULATIONS WHEN COMPARED TO MANUAL MANIPULATIONS WHEN COMPARED TO MANUAL LAPAROSCOPY”LAPAROSCOPY”

“ “PREVIOUS EXPOSURE TO LAPAROSCOPY ENABLES A PREVIOUS EXPOSURE TO LAPAROSCOPY ENABLES A SURGEON TO SURGEON TO INCORPORATE ROBOTICS MORE RAPIDLY THAN A SURGEON INCORPORATE ROBOTICS MORE RAPIDLY THAN A SURGEON WITH WITH NON PREVIOUS KNOWLEDGE OF MINIMAL INVASIVE NON PREVIOUS KNOWLEDGE OF MINIMAL INVASIVE SURGERY”SURGERY”

“ “HOWEVER IT IS DIFFICULT TO ESTABLISH GUIDELINES FOR HOWEVER IT IS DIFFICULT TO ESTABLISH GUIDELINES FOR CLINICAL TRAINING SOLELY FROM THIS DRY-LAB DATA”CLINICAL TRAINING SOLELY FROM THIS DRY-LAB DATA”

HANCE J ET AL: J MEDICAL ROBOTICS AND COMPUTER ASSISTED SURGERY, 2005 HANCE J ET AL: J MEDICAL ROBOTICS AND COMPUTER ASSISTED SURGERY, 2005

RISULTATI RISULTATI

PROCEDURE: 43PROCEDURE: 43

DEGENZA MEDIA: 48.6 hDEGENZA MEDIA: 48.6 h

MORTALITA’:MORTALITA’: 0 0

MORBILITA’:MORBILITA’: 3 3

- OCCLUSIONE INTESTINALE: 1- OCCLUSIONE INTESTINALE: 1

- EMORRAGIA SITO TROCAR - EMORRAGIA SITO TROCAR ACCESSORIO: 2ACCESSORIO: 2

IT IS NECESSARY TO STANDARDIZE PROCEDURES AND ESTABLISH IT IS NECESSARY TO STANDARDIZE PROCEDURES AND ESTABLISH

OPERATIVE SCHEMES AND TRAINING PROTOCOLS FOR THIS OPERATIVE SCHEMES AND TRAINING PROTOCOLS FOR THIS

THECNOLOGYTHECNOLOGY

ADEQUATE TRAINING WILL ALLOW THE CREATION OF SURGICAL ADEQUATE TRAINING WILL ALLOW THE CREATION OF SURGICAL

TEAM TEAM

(SURGEONS, ANESTHESIOLOGISTS, OPERATING ROOM (SURGEONS, ANESTHESIOLOGISTS, OPERATING ROOM

PERSONNEL) ABLE PERSONNEL) ABLE

TO ACTIVATE AND MANTEIN THE ENTIRE OPERATIVE SYSTEM AND TO ACTIVATE AND MANTEIN THE ENTIRE OPERATIVE SYSTEM AND

TO TO

APPLIE THE ROBOTIC THECHNIQUE IN MANY SUIRGICAL APPLIE THE ROBOTIC THECHNIQUE IN MANY SUIRGICAL

PROCEDURESPROCEDURES

TRAINING MUST BE DEDICATED TO SURGEONS WITH PREVIOUS TRAINING MUST BE DEDICATED TO SURGEONS WITH PREVIOUS

KNOWLEDGE OF CONVENTIONAL AND MINIMAL INVASIVE KNOWLEDGE OF CONVENTIONAL AND MINIMAL INVASIVE

SURGERYSURGERY

CONCLUSIONSCONCLUSIONS

FUTURE TRAININGFUTURE TRAINING

VIRTUAL REALITY SIMULATORVIRTUAL REALITY SIMULATOR - - www.simsurgery.com (Norway) (Norway)

- - Two Handed Universal Master Console (THUMP)Two Handed Universal Master Console (THUMP)

TELEMENTORINGTELEMENTORING

ENHANCEMENT OF SURGEON’S VIEWENHANCEMENT OF SURGEON’S VIEW - - Simulation and Transfer Architecture for Robotic Surgery Simulation and Transfer Architecture for Robotic Surgery (STARS)(STARS)

FUTURE TRAININGFUTURE TRAINING

HIGH TECHNOLOGY FORMATION HIGH TECHNOLOGY FORMATION

MEDICAL LEGAL IMPLICATIONSMEDICAL LEGAL IMPLICATIONS