Robotics In General Surgery - Ccme.osu.edu

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Robotics inGeneral SurgeryJennifer S. Schwartz, MDAssistant Professor of SurgeryDepartment of SurgeryDivision of General & Gastrointestinal SurgeryThe Ohio State University Wexner Medical CenterObjectives Brief History of Robotics in General Surgery Robotic General Surgery Procedures Advantages/Disadvantages of Robotic General Surgery Role of Robotic Surgery in Bariatric Surgery Role of Robotic Surgery in Foregut Surgery Role of Robotic Surgery in Ventral Hernia Surgery1

History Multiple previous robotic devices createdincluding Puma 560 (1985) for neurosurgicalbiopsies, AESOP (1993) for robotic assistedendoscopic surgeries, and ROBODOC for hipreplacement surgery In 2000, the da Vinci Surgical System receivedFDA approval for minimally invasive surgery. Ohio State was one of the first robotic centerworldwide (2000) First reports of robotic Heller myotomy (2001),Pancreatic resection (2001), and Four armsurgery (2004).ROBODOCLanfranco AR1, Castellanos AE, Desai JP, Meyers WC. Robotic Surgery: ACurrent Perspective. Ann Surg. 2004 Jan;239(1):14-21.19992

Si System2017Xi SystemAuthor: Cmglee(CC BY-SA 3.0)(U.S. Air Force photo byKemberly Groue/Released)Author: IntuitiveSurgical (CC BY-SA 3.0)da Vinci Robot Initially developed for Cardiac Surgery use Ultimately expanded to other specialtieswith specific traction in Urology andGynecology Over 3,100 systems worldwide3

2017 Intuitive Surgical, Inc. 2017 Intuitive Surgical, Inc.4

National Trends in Hernia Repair by SurgicalApproach180%60%DAVINCILAP40%OPEN19%20%PN 1027535-US Rev 1. Analysis of 2008-2015 Premier database. Primary procedure.2. 2016 da Vinci market penetration projection based on Goldman Sachs Financial Model 02/06/16 2017 Intuitive Surgical, Inc.Advantages 3 dimensional viewing Wrist articulation 2017 Intuitive Surgical, Inc. Increased ability to perform fine dissection Minimally invasive approach to previousopen procedures Better ergonomics for surgeons5

Disadvantages Cost- Capital investment- Instruments – 10 use Longer Surgery Duration Learning Curve Patient advantage?Robotic GeneralSurgery ProceduresFDA Approved procedures:- Bariatric procedures (sleeve, gastric bypass)- Foregut Surgery: Nissen fundoplication,Heller Myotomy- Gastrectomy (benign, malignant)- Hernia repair- Cholecystectomy- Pancreatectomy (benign, malignant)- Colectomy- Rectal resection6

BariatricSurgeryThe Obesity Epidemic- 78.6 million (34.9%) Americans areconsidered obese- More than doubled from 13.3% in 1960- Obesity-related conditions affect nearlyevery organ systemand are some of the leading causes ofpreventable deaths- www.cdc.gov7

Estimate of Bariatric SurgeryNumbers, %BPD/DS0.9%1%1%0.4%0.6%Revisions 6%6%6%11.5%13.6%Other2.3%2.7%0.1%3.2%3.2%Balloons 700casesV-Bloc18 casesASMBS total bariatric procedures numbers from 2011, 2012, 2013, 2014 and 2015 arebased on the best estimation from available data (BOLD, ASC/MBSAQIP, NationalInpatient Sample data and outpatient estimations).asmbs.orgRobotic Bariatric SurgeryRoux-en-Y Gastric BypassSleeve GastrectomyImages from https://en.wikipedia.org/wiki/Gastric bypass surgery8

Robotic Bariatric Surgery Advantages: Studies have shown at least equal outcomesto laparoscopic surgery May decrease gastrojejunostomy leak rate,stricture rate, length of stay Disadvantages: Procedure length of time Cost? More studies needed to determine if there is atrue patient benefitForegut Surgery9

Robotic Foregut Surgery Hiatal hernia repair with Nissen (360⁰) or Toupet(270⁰) fundoplication Paraesophageal hernia 00181 5.htmRobotic Foregut Surgery10

Robotic Foregut Surgery Heller myotomy for achalasiaAuthor: Farnoosh Farrokhi, Michael F. Vaezi. - CC BY 2.0Robotic Foregut Surgery Advantages of Robotic Foregut Surgery: 3D Visualization Magnification of Surgical Field Very useful for redo operations wheremore precise movement are needed Very useful for Heller myotomy forachalasia where precise division ofmuscle fibers is critical to preventesophageal perforation11

Ventral HerniaRepairAdvantages: MinimallyInvasive Approach Minimally invasive hernia repairs are associatedwith shorter length of stay, fewer wound-relatedcomplications, improved postoperative painprofiles Limitations of Laparoscopic ventral hernia repair: intraperitoneal mesh placement difficult to re-approximate the midline high cost of mesh and fixation devices Bulging/Eventration of the mesh with largerdefects Technique not always equal to open12

Robotic Pre-Peritoneal VentralHernia Repair – videoAdvantages: MinimallyInvasive Approach Robotic ventral hernia repair may bridge the gapbetween open and laparoscopic repairs Robotic ventral hernia repair allows for largerdefects to be repaired minimally invasivelyincluding myofascial releases: Transversus abdominus release (TAR) External oblique release Bilateral postrectus sheath incision withretrorectus hernia repairGonzalez, A., Escobar, E., Romero,R. et al. Surg Endosc (2016).13

Advantages: MinimallyInvasive Approach Retrorectus herniarepair: brings fascialedges to the midlineto create a morefunctional abdominalwallAdvantages: MinimallyInvasive Approach Recent study compared length of stay ofrobotic retrorectus ventral hernia repair(r-RVHR) to open retrorectus ventralhernia repair (o-RVHR) Evaluating value added to patients andthe health system by assessing onecomponent, length of stayCarbonell AM, et. al. Ann Surg. 2017 Mar 2714

Advantages: MinimallyInvasive ApproachRobotic Retrorectus VentralHernia Repair – Video15

Advantages: MinimallyInvasive Approach Utilizing data from the Americas HerniaSociety Quality Collaborative (AHSQC),evaluated the largest collection of r-RVHR todate. Length of Stay (statistically significant): r-RVHR – 2 days o-RVHR – 3 days Despite the increased cost of roboticplatform, cost savings was noted fromdecreased length of stay, mesh choice.Carbonell AM, et. al. Ann Surg. 2017 Mar 27Current Status of Robotics in Hernia Growing experience and increasing numberof studies, however still very little dataavailable Literature primarily single surgeon experience Largest study: Multicenter retrospective study 368 patients underwent robotic primary or incisional herniarepair by 5 surgeons Reproducibly safe Short term outcomes comparable to laparoscopic results Scrutiny over cost vs. benefitGonzalez, A., Escobar, E., Romero, R. et al.Surg Endosc (2016).16

Robotics in General SurgeryReferences1. Lanfranco AR1, Castellanos AE, Desai JP, Meyers WC. RoboticSurgery: A Current Perspective. Ann Surg. 2004 Jan;239(1):14-21.2. asmbs.org3. https://medlineplus.gov/ency/presentations/100181 5.htm4. https://www.sages.org/publications/5. Carbonell AM1, Warren JA, Prabhu AS, Ballecer CD, Janczyk RJ,Herrera J, Huang LC, Phillips S, Rosen MJ, Poulose BK. ReducingLength of Stay Using a Robotic-assisted Approach for RetromuscularVentral Hernia Repair: A Comparative Analysis From the AmericasHernia Society Quality Collaborative. Ann Surg. 2017 Mar 27. doi:10.10976. Gonzalez, A., Escobar, E., Romero, R. et al. Robotic-assisted ventralhernia repair: a multicenter evaluation of clinical outcomes. SurgEndosc (2016). doi:10.1007/s00464-016-511.8-017

Robotics inGeneral SurgeryMichael Paul Meara, MD, MBA, FACSAssistant Professor of SurgeryCenter for Minimally Invasive SurgeryDivision of General & Gastrointestinal SurgeryThe Ohio State University Wexner Medical CenterObjectives Role of Robotic Surgery in Inguinal HerniaSurgery Role of Robotic Surgery in Biliary Surgery Role of Robotic Surgery in SurgicalResident Education18

Inguinal HerniaRepairInguinal Hernia Repairs Wide Variety of Repairs Open Tissue Repairs Open Mesh Repairs Laparoscopic Mesh Repairs Totally Extraperitoneal Trans Abdominal Repairs Robotic Mesh Repairs19

Advantages: MIS Inguinal Approaches Both open and minimally invasive inguinal herniarepairs continue to be largely outpatientprocedures. Minimally invasive inguinal hernia repairs areassociated with: Smaller incisions Fewer wound-related complications and meshinfections Improved postoperative pain profiles Fewer complications related to chronic nerveissues Bowel evaluation in emergent casesLimitations: MIS InguinalApproaches Limitations of Laparoscopic Inguinal herniarepair: Steep learning curve High cost of fixation devices Difficulty managing larger defects Technique not always equal to open Previous Repairs may necessitatedifferent approaches20

Robotic BilateralInguinal Hernia RepairAdvantages: Robotic MinimallyInvasive Approach Robotic inguinal hernia repair avoid costlyfixation devices Robotic inguinal hernia repair mayprovide improved ergonomics to thesurgeon during placement.21

Biliary SurgeryLaparoscopicCholecystectomy First performed in September of 1985. Popularized as Standard of Care Gave birth to the Laparoscopic Revolutionof Surgery Continues to be one of the most commonprocedures performed in the United States22

Minimally Invasive Advancesin Biliary Surgery Fluorescence imaging popularize forimproved anatomic identification andprevention of complications Continues to push the boundaries of MISsurgeries including complex cancerresections and reconstructions Provides a stable platform for resident andfellow trainingRobotic Cholecystectomywith Fluorescence Imaging23

Robotics in Residentand FellowshipTraining 2017 Intuitive Surgical, Inc.24

National Trends in Hernia Repair by SurgicalApproach180%60%DAVINCILAP40%OPEN19%20%PN 1027535-US Rev 1. Analysis of 2008-2015 Premier database. Primary procedure.2. 2016 da Vinci market penetration projection based on Goldman Sachs Financial Model02/06/16 2017 Intuitive Surgical, Inc.Robotic TrainingRequirements Online surgical system course work Simulation modules with passing metrics Beside assisting cases Primary cases as the Console Surgeon Simulation modules with passing metrics25

Robotics in General Surgery26

Jennifer S. Schwartz, MD Assistant Professor of Surgery Department of Surgery Division of General & Gastrointestinal Surgery The Ohio State University Wexner Medical Center Robotics in General Surgery Objectives Brief History of Robotics in General Surgery Robotic General Surgery

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