Colorectal endoscopic submucosal dissection in the USA: The current state and future perspectives.

Endoscopic submucosal dissection (ESD) is a transformative advancement in the endoscopic management of superficial gastrointestinal lesions. Initially conceived for the treatment of early gastric cancer, ESD has demonstrated proficiency in achieving en-bloc resection of superficial gastrointestinal lesions. ESD has experienced widespread acceptance in Japan and East Asia; however, its adoption in the USA remains delayed. This initial hesitancy could be attributed to procedural complexity and training demands; nonetheless, recently, ESD has been gaining popularity in the USA. This is due to the advancements in endoscopic technology, tailored training programs, and cumulative evidence regarding the efficacy and safety of ESDs. This review aimed to deliberate the historical progress, current implementation, and prospective trajectory of ESDs in the USA. With ongoing clinical research, technological integration, and educational efforts, ESD is likely to become the gold standard for managing large gastrointesitinal lesions. This progress marks an imperative step toward less invasive, more precise, and patient-centric approaches regarding advanced therapeutic endoscopy in the USA.

A Robotic Clamped-Kinematic System to Study Knee Ligament Injury.

Knee ligament injury is among the most common sports injuries and is associated with long recovery periods and low return-to-sport rates. Unfortunately, the mechanics of ligament injury are difficult to study in vivo, and computational studies provide limited insight. The objective of this study was to implement and validate a robotic system capable of reproducing natural six degree-of-freedom clamped-kinematic trajectories on human cadaver knees (meaning that positions and orientations are rigidly controlled and resultant loads are measured). To accomplish this, we leveraged the field's recent access to high-fidelity bone kinematics from dynamic biplanar radiography (DBR), and implemented these kinematics in a coordinate frame built around the knee's natural flexion-extension axis. We assessed our system's capabilities in the context of ACL injury, by moving seven cadaveric knee specimens through kinematics derived from walking, running, drop jump, and ACL injury. We then used robotically simulated clinical stability tests to evaluate the hypothesis that knee stability would be only reduced by the motions intended to injure the knee. Our results show that the structural integrity of the knee was not compromised by non-injurious motions, while the injury motion produced a clinically relevant ACL injury with characteristic anterior and valgus instability. We also demonstrated that our robotic system can provide direct measurements of reaction loads during a variety of motions, and facilitate gross evaluation of ligament failure mechanisms. Clamped-kinematic robotic evaluation of cadaver knees has the potential to deepen understanding of the mechanics of knee ligament injury.

How i do it: Robot-assisted transcerebellar stereotactic approach for brainstem lesion.

BACKGROUND: Stereotactic approaches to diffuse intrinsic pontine gliomas (DIPGs) remain essential due to advances in molecular biology and management, necessitating tissue sampling. Here we present an effective technique with a biopsy by robot-assisted transcerebellar approach. METHOD: Our procedure was performed using the ROSA robotic system and the OARM CT scan, which provided stereotactic conditions for this transcerebellar approach to brainstem lesions. CONCLUSION: The robot-assisted transcerebellar stereotactic approach remains essential to provide complications for biopsy of brainstem lesions.

Comparison of robotic versus laparoscopic total gastrectomy for gastric cancer: A single-center retrospective cohort study in a Japanese high-volume center.

BACKGROUND: Robotic-assisted surgery has become increasingly popular worldwide in recent years. This study aimed to compare the surgical outcomes of robotic total gastrectomy (RTG) and laparoscopic total gastrectomy (LTG) to figure out the advantages of RTG. METHODS: The eligible cases in this study were patients who underwent RTG or LTG for gastric adenocarcinoma at our hospital from January 2014 to December 2022. Propensity score matching (PSM) was employed to balance the underlying selection bias. Then, surgical outcomes of patients were analyzed to be compared. RESULTS: Overall, 255 patients (LTG: 178, RTG: 77) were included in this study. After PSM, 73 patients in each arm were assigned for analysis. Operation time was longer in the RTG than in the LTG (373 vs 336 min, p < 0.01). However, the RTG was associated with shorter postoperative hospital stays (8 vs 9 days, p = 0.04) and lower incidence of grade 3 or higher postoperative complications (1 % vs 11 %, p = 0.03). More lymph nodes were harvested in the RTG (59 vs 47, p < 0.01). CONCLUSIONS: Although RTG requires longer operation time, it has the potential to provide advantages to the patient such as quicker recovery, reduction in postoperative complication, or more yield number of lymph nodes. Regarding survival outcomes, further analysis with enough follow-up is needed.

Task-space tracking for networked heterogeneous robotic systems via adaptive neural fixed-time control.

The task-space distributed adaptive neural network (NN) fixed-time tracking problem is studied for networked heterogeneous robotic systems (NHRSs). In order to address this complex problem, we propose a NN-based fixed-time hierarchical control approach that transforms the problem into two sub-problems: a distributed fixed-time estimation problem and a local fixed-time tracking problem, respectively. Specifically, distributed estimators are constructed so that each follower can acquire the dynamic leader's state in a fixed time. Then, the neural networks (NNs) are employed to approximate the compounded uncertainty consisting of the unknown dynamics of robotic systems and the boundary of the compounded disturbance. More importantly, to guarantee that the tracking errors can converge into a small neighborhood of equilibrium in a fixed time independent of the initial state, the adaptive neural fixed-time local tracking controller is proposed. Another merit of the proposed controller is that the approximation errors are addressed in a novel way, eliminating the need for prior precise knowledge of uncertainties and improving the robustness and convergence speed of unknown robotic systems. Finally, the experimental results demonstrate the effectiveness and advantages of the proposed control method.

3D monitors improve performance on the HUGO™ RAS system: a randomised trial.

BACKGROUND: Robot-assisted surgery is used worldwide, allowing surgeons to perform complex surgeries with increased precision and flexibility. It offers technical benefits compared to traditional laparoscopic surgery due to its utilization of both 3D vision and articulated instruments. The objective was to investigate the isolated effect of 3D- versus 2D monitors when working with articulated instruments in robot-assisted surgery. METHODS: Surgical novices (medical students, n = 31) were randomized to simulation-based training with either the 3D vision switched on or off. Both groups completed each of the four exercises six times over two sessions on the Medtronic Hugo™ RAS system simulator. The outcome was the simulator performance parameters and a visual discomfort questionnaire. RESULTS: For the efficiency parameters, we found that both groups improved over time (p < 0.001) and that the intervention group (3D) consistently outperformed the control (2D) group (p < 0.001). On the other hand, we didn't find any significant difference in the error metrics, such as drops (p-values between 0.07 and 0.57) and instrument collisions (p-values between 0.09 and 0.26). Regarding Visual Discomfort, it was significantly more difficult for the 3D group to focus (p = 0.001). CONCLUSION: 3D monitors for an open robotic console improve efficiency and speed compared to 2D monitors in a simulated setting when working with articulated instruments.

A Case of Robotic Cholecystectomy in a Patient With Decompensated Cirrhosis and Portal Hypertension.

In patients with liver cirrhosis, approximately one-third experience pigmented cholelithiasis. In parallel to this, cirrhotics consequently encounter a greater prevalence of acute cholecystitis. Traditionally, the definitive treatment for acute cholecystitis in non-cirrhotic patients is cholecystectomy. However, decompensated cirrhosis and portal hypertension pose a surgical challenge, as these comorbidities increase the risk of postoperative complications such as bleeding, infection, and multi-organ failure. Therefore, it is of utmost importance to consider patient risk factors, anatomy, and acuity of patient cholecystitis on an individual basis and develop a surgical (or non-surgical) plan that minimizes risk to patients with decompensated cirrhosis and portal hypertension. We present the management strategies of a case of a 50-year-old male who presents with a history of decompensated liver cirrhosis and portal hypertension complicated by acute cholecystitis. Upon initial presentation, he was critically ill, and a percutaneous cholecystostomy tube was placed for management and the patient was instructed to follow up in the clinic. Then, the patient later returned to the emergency department with a fever, UTI, and sepsis. At that time, his cholecystostomy tube continued to have bilious drainage and he had tenderness in the right upper quadrant. The decision was made to proceed with surgery. Because of his significant comorbid conditions and underlying cirrhosis, surgery posed an increased risk. For this patient, it was especially important to evaluate the risk of complications and the decision of open vs laparoscopic cholecystectomy. In this patient, robotic-assisted laparoscopic cholecystectomy was eventually performed. Due to the patient's hepatomegaly, splenomegaly, and portal hypertension, special consideration was needed for trocar placement. In this case, we aim to exemplify that is of utmost importance to consider patient anatomy by using imaging and marking organ borders to inform trocar placement as part of the surgical approach.

Robotic Repair of Acute Traumatic Diaphragmatic Injury From an Abdominal Approach: A Case Report.

Traumatic diaphragmatic injury is a rare condition with a significant mortality risk and may cause a herniation of an intraperitoneal organ into the pleural space. In the acute phase, traumatic diaphragmatic hernia (TDH) may be repaired with laparotomy or thoracotomy and is often associated with multiple concurrent injuries. This case report highlights a rare clinical scenario of blunt traumatic DH in a 62-year-old male with approximately seven centimeters of stomach herniating into the left pleural space, repaired with minimally invasive surgery. This was done via a transabdominal approach with robotic-assisted laparoscopic hernia repair and institution of biologic mesh and represents an important opportunity that potentially reduces the morbidity risk involved with open surgeries.

Effects of robotic rehabilitation on fatigue experience, disability, and quality of life in patients with multiple sclerosis (MS): A systematic review and meta-analysis.

Background: Rehabilitation plays an important role in improving symptoms in patients with multiple sclerosis (MS). There are studies evaluating the effects of robotic rehabilitation in patients with MS, but the results varied between the studies. So, we designed this systematic review and meta-analysis to estimate pooled effects of robotic rehabilitation on fatigue, disability, and quality of life in subjects with MS. Methods: We systematically searched PubMed, Scopus, EMBASE, Web of Science, Google Scholar, and also gray literature including references of the included studies, and also conference abstracts on October 1th 2022. Data regarding the total number of participants, first author, publication year, country of origin, mean age, EDSS, and results of fatigue and quality of life were recorded. Results: The first literature search revealed 6878 results, after deleting duplicates, 5019 studies remained. Two researchers, evaluated the titles and abstracts, and finally 77 full texts were assessed. For meta-analysis, we included 11 studies. The pooled Standardized Mean Difference (SMD) of Kurtzke Expanded Disability Status Scale (EDSS) (after-before) estimated as -0.56 (95%CI: -0.89,-0.23). The pooled SMD of Fatigue Severity Scale (FSS) estimated as -0.54(95%CI: -1.06, -0.01) (I2=66.7%, P=0.01). The pooled SMD of physical health subscale of multiple sclerosis quality of life (MSQOL-54) estimated as 0.36(95%CI:-0.23, 0.96) (I2=51.4%, P=0.1). The pooled SMD of mental health subscale of MSQOL54 estimated as 0.48 (95%CI: 0.07, 0.88) (I2=0%, P=0.6). Conclusions: The results of this systematic review and meta-analysis show that robotic rehabilitation has positive effects on fatigue, and disability in patients with MS.

Feasibility, clinical outcomes, and learning curves of robotic-assisted colorectal cancer surgery in a high-volume district general hospital: a cohort study.

Introduction: Robotic-assisted surgery (RAS) is one of the most influential surgical advances with widespread clinical and health-economic benefits. West Hertfordshire Teaching Hospital NHS Trust was the first in the UK to simultaneously integrate two CMR Surgical Versius robots. This study aims to investigate clinical outcomes of RAS, explore surgeon learning curves and assess the feasibility of implementation within a district general hospital (DGH). Methods: A prospective cohort study of 100 consecutive patient data were collected between July 2022 and August 2023, including demographics, operative and clinical variables, and compared with laparoscopic surgery (LS) data from the National Bowel Cancer Audit. Surgeon learning curves were analysed using sequential surgical and console times. Results: In the RAS cohort, the median age was 70 (IQR 57-78 years) and 60% were male. Retrieval of a minimum of 12 lymph nodes significantly increased in RAS compared to LS (95% vs. 88%, P=0.05). The negative mesorectal margin rate was similar between RAS and LS (97% vs. 91%, P=0.10), as well as length of stay greater than 5 days (42% vs. 39%, P=0.27). For anterior resections performed by the highest volume surgeon (n=16), surgical time was reduced over 1 year by 35% (304.9-196.9 min), whilst console time increased by 111% (63.0-132.8 min). Conclusions: Key quality performance indicators were either unchanged or improved with RAS. There is potential for improved theatre utilisation and cost-savings with increased RAS. This study demonstrates the feasibility and easy integration of robotic platforms into DGHs, offering wider training opportunities for the next generation of surgeons.

Functional Outcome in Obese Patients Undergoing Image-Based Cruciate Retaining Robotic-Assisted Total Knee Arthroplasty Using the Subvastus Approach: A Short-Term Study.

Introduction Knee osteoarthritis (OA) is a prevalent degenerative joint disease that significantly affects quality of life, especially among obese and morbidly obese individuals. Total knee arthroplasty (TKA) is an effective treatment for end-stage OA, but it presents unique challenges in obese patients. The mini-subvastus approach (SA) and robotic-assisted TKA (RA-TKA) are emerging techniques that may address these challenges. This study evaluates the clinical and radiological outcomes of cruciate-retaining (CR) RA-TKA using the mini-subvastus approach in obese and morbidly obese patients. Methods This study included 114 obese patients (215 knees) with primary OA who underwent CR RA-TKA (Maxx Meril CR knee, USA) using the Cuvis Joint® robotic system. Patients had a BMI of ≥30 kg/m² (n=101) and morbid obesity with a BMI ≥40 kg/m² (n=13). Preoperative planning involved CT scans and the J-planner for optimal implant size and positioning. Surgery was performed without tourniquets, and patients were mobilized postoperatively. Clinical outcomes were assessed using visual analog scale (VAS) scores and the American Knee Society Score (AKSS) at three and six months. Results The study included 85 females and 29 males with an average age of 61.8 years. Satisfactory knee exposure was achieved in all cases using SA, with no major complications such as wound infections, deep vein thrombosis, or component misalignment. Intraoperative challenges were managed effectively, including two cases of medial collateral ligament avulsion and one partial patellar tendon avulsion. Postoperative VAS scores showed significant pain reduction from pre-op (6.54) to post-op day 3 (1.3). AKSS improved from a pre-op average of 33.9 to 70.7 at three months and 80.9 at six months. Most patients (80%) achieved exceptional range of motion (ROM) ≥120° at six months. Discussion The mini-subvastus approach in RA-TKA offers several advantages, including reduced postoperative pain, faster recovery, and improved quadriceps strength, even in obese patients. The use of robotic assistance ensures accurate component positioning and alignment, mitigating the challenges typically associated with obese patients undergoing TKA. Conclusion The study demonstrates the feasibility and effectiveness of CR RA-TKA using the mini-subvastus approach in obese and morbidly obese patients. This technique provides adequate exposure, reduces pain, and promotes early mobilization and recovery with satisfactory clinical and radiological outcomes. The findings support the potential for wider adoption of this approach in managing knee OA in obese populations, though further studies with longer follow-up are warranted.

A Unique Case of Gastric Band Tubing Eroding Into the Vaginal Cuff.

We present here the case of a woman in her 40s with a history of an adjustable gastric band placed a decade ago. After the initial procedure, she had issues with a port-site hernia, mesh placement, and explantation secondary to mesh infection. Her port was removed at the time, with the tubing left in situ with hopes of future salvage. She then presented to her gynecologist with the tubing eroding through her vaginal cuff. This case highlights the importance of having a high index of suspicion in patients with a history of gastric bands given the varying presentation in the event of a complication.

Beyond the Learning Curve of Robot-Assisted Navigation Spine Surgery: Refinement of Outcomes With Extended Experience.

Objective This study assessed whether robotic-assisted navigation (RAN) spine surgery outcomes, including operative time and pedicle screw accuracy, continue to improve with extended experience beyond 200 cases. Methods This is a retrospective review of 60 patients who underwent lumbosacral transforaminal interbody fusion using RAN. Patients were segmented into three groups of 20 consecutive cases each. The first group represented a surgical performance baseline leading up to the investigating surgeon's 200th RAN case. The subsequent two groups were selected beyond the 200th case with an average of 15 cases between groups. Pedicle screw accuracy and intraoperative outcomes were assessed. Statistical results were significant if p<0.05. Results Measures of surgical efficiency significantly improved beyond the investigating surgeon's 200th RAN case. As case number increased, the following parameters significantly decreased: registration time (group 1: 16.9±6.5, group 2: 12.9±3.0, group 3: 8.7±1.6 minutes; p<0.05), screw insertion time (group 1: 14.9±3.5, group 2: 10.9±2.0, group 3: 8.4±2.7 minutes; p<0.05), and total operative time significantly decreased from group 1 (175.9±58.2 minutes) to group 2 (135.8±23.9 minutes) (p=0.013) with a non-significant decrease to group 3 (121.5±32.3 minutes). Accuracy (Grade = A) significantly increased across groups (group 1: 87%, group 2: 94%, group 3: 98%; p=0.024). Group 1 had the highest misplacement rate of 3.7% (4/108 screws). The overall misplacement rate was 1.4% (4/290 screws) (Grade C-E). There was a higher rate of lateral screw misplacement compared to medial misplacement. Conclusion Even with a small number of initial cases, RAN spine surgery can consistently be performed with high accuracy and acceptable intraoperative outcomes. However, this study demonstrated refined outcomes with extended robotic experience.

Portal Vein Arterialization as a Lifesaving Strategy for Hepatic Artery Injury in Robotic Hepatectomy.

BACKGROUND: Robotic vascular resection and reconstruction is a challenging procedure. Portal vein arterialization (PVA) can offer an efficient solution in those cases in which the hepatic artery cannot be reconstructed.1.Can J Surg 64:e173-e182;2.The Paul Brousse Hospital Experience. HPB (Oxford) 16:723-738;3.J Am Coll Surg 207:e1-6; PVA increases oxygen supply to the remaining part of the liver, promotes liver regeneration, and prevents liver failure.Majlesara A, Golriz M, Ramouz A, et al. Portal vein arterialization as a salvage method in advanced hepatopancreatobiliary surgery. Br J Surg. 2024;111. In this multimedia article, we describe a patient who was treated with PVA for a robotic hepatic artery injury during robotic left-liver-first anterior radical modular orthotopic right hemihepatectomy (Rob-Larmorth).5.Ann Surg Oncol 31:5636-5637 METHODS: A 52-year-old male patient was admitted with epigastric pain. Further imaging showed intrahepatic cholangiocarcinoma involving the root of the right anterior branch of the portal vein. Following multidisciplinary consultation, surgical resection was recommended as the primary approach. The robotic technique was chosen in this operation, with preoperative anticipation of needing Rob-Larmorth. Unfortunately, the left hepatic artery sustained unintended damage during skeletonization of the duodenal ligaments. Anastomosis could not be performed due to severe damage to the distal end intima. We utilized PVA technology to anastomose the hepatic artery to the portal vein. Finally, Rob-Larmorth and PVA were successfully performed. RESULTS: The surgery took 490 min and the estimated blood loss was approximately 300 mL. No blood transfusion was performed. Postoperatively, the patient recovered smoothly without liver failure, although percutaneous drainage was required due to bile leakage. Pathological examination revealed moderately to poorly differentiated bile duct cell carcinoma (T2N0M0, stage II). No recurrence was observed during the 12-month follow-up. DISCUSSION: PVA can be an effective solution when no other revascularization options are available. Implementing PVA as a bridging procedure increases oxygen delivery to the remnant liver, facilitating regeneration and reducing the risk of liver failure. The development of arterial collaterals is a significant concern for individuals undergoing PVA. Complications reported after PVA include early shunt thrombosis, portal hypertension, and a notable 90-day mortality rate.1.Can J Surg 64:e173-e182 However, Majlesara and colleagues found no evidence of postoperative liver damage associated with PVA. They also reported low morbidity rates and no associated mortality for both one- and two-stage embolization of the arterioportal shunt.Majlesara A, Golriz M, Ramouz A, et al. Portal vein arterialization as a salvage method in advanced hepatopancreatobiliary surgery. Br J Surg. 2024;111. CONCLUSIONS: PVA can offer an effective solution when hepatic artery reconstruction is not feasible.

Robotic-Assisted Versus Open Hemi-Hepatectomy: A Propensity Score Analysis.

INTRODUCTION: The robotic-assisted surgical system has been widely used in hepatectomy. However, the effectiveness and feasibility of robotic-assisted hemi-hepatectomy (RH) has not been well-documented. METHODS: Patients who underwent RH or open hemi-hepatectomy (OH) performed by a single surgeon at our hospital between January 2010 and August 2023 were included in this study. A stabilized inverse probability of treatment weighting adjusted analysis was performed. RESULTS: Of the 163 consecutive patients identified, 60 underwent RH, and 103 underwent OH. After stabilized inverse probability of treatment weighting adjustment, RH demonstrated less blood loss than OH. In subgroup analyses, robotic-assisted left hemi-hepatectomy was associated with a shorter postoperative stay, a lower postoperative complication rate, and less blood loss compared with open left hemi-hepatectomy. While robotic-assisted right hemi-hepatectomy (RRH) was associated with less blood loss and a lower intraoperative blood transfusion rate, but a longer operation time compared with open right hemi-hepatectomy. CONCLUSIONS: RH is a safe and effective technique. In addition to less blood loss, robotic-assisted left hemi-hepatectomy had advantages in postoperative complications and postoperative stay, while RRH had advantages in intraoperative blood transfusions. However, operation time was longer for RRH than for open right hemi-hepatectomy.

Effect of training method and dairy cow personality traits on adaptation to an automated milking system.

Training dairy cows on the automated milking system (AMS) can improve their performance, however, the ideal training method and how their individual personality relates to training is unknown. The objectives of this study were to determine: 1) the effect of AMS training method on adaptation of primiparous cows to an AMS, 2) whether the personality of a cow affects their adaptation to the AMS, and 3) whether certain personality types adapt better based on the type of training they receive. Forty-eight primiparous Holstein dairy cows, who had not previously been milked by an AMS, were enrolled in the study at ∼85 DIM and were assessed for personality traits using a combined arena test comprised of 3 parts: a novel arena test, a novel object test, and a novel human test. Cows were allocated into 1 of 4 AMS training treatments (n = 12): control (CON; no training), environment exposure only (ENV), environment and AMS concentrate provision (PEL), and environment and mechanics exposure (MEC). Cows in the ENV, PEL, and MEC treatments were subjected to training 4 × /d for 4 d, and then cows from all 4 treatments were milked on the AMS in the evening of the 4th training d. Milking activity and production were recorded for the first 14 d on the AMS. PEL cows had fewer visits to the AMS, fewer milkings, and fewer voluntary milkings compared with CON cows across the 14 d. Cows on all experimental treatments had more fetching events than CON cows, while MEC and ENV treatment cows had a higher milk yield compared with those on the CON treatment. Principal component analysis of the behaviors recorded during the personality assessment revealed 2 factors interpreted as personality traits, "explore-active" and "bold." Across all cows, more "explore-active" cows had greater milk yield. Only the performance of ENV cows was associated with personality; ENV cows who scored low for "explore-active" differed from CON cows, through increased visits and voluntary milkings. Overall, the results demonstrate that providing concentrate on its own during AMS training may not be motivating enough to improve adaptation and performance. However, exposing cows to the mechanics (e.g., the robotic arm and sounds of the AMS) before first milking may improve milk yield. Finally, cow personality may influence the performance of cows trained using less complicated training methods, such as only exposing them to the environment of the AMS.

Siamese and triplet network-based pain expression in robotic avatars for care and nursing training.

Care and nursing training (CNT) refers to developing the ability to effectively respond to patient needs by investigating their requests and improving trainees' care skills in a caring environment. Although conventional CNT programs have been conducted based on videos, books, and role-playing, the best approach is to practice on a real human. However, it is challenging to recruit patients for continuous training, and the patients may experience fatigue or boredom with iterative testing. As an alternative approach, a patient robot that reproduces various human diseases and provides feedback to trainees has been introduced. This study presents a patient robot that can express feelings of pain, similarly to a real human, in joint care education. The two primary objectives of the proposed patient robot-based care training system are (a) to infer the pain felt by the patient robot and intuitively provide the trainee with the patient's pain state, and (b) to provide facial expression-based visual feedback of the patient robot for care training.