Efficacy of robot arm-assisted endoscopic submucosal dissection in live porcine stomach (with video).

Endoscopic submucosal dissection (ESD) is technically challenging and requires a high level of skill. However, there is no effective method of exposing the submucosal plane during dissection. In this study, the efficacy of robot arm-assisted tissue traction for gastric ESD was evaluated using an in vivo porcine model. The stomach of each pig was divided into eight locations. In the conventional ESD (C-ESD) group, one ESD was performed at each location (N = 8). In the robot arm-assisted ESD (R-ESD) group, two ESDs were performed at each location (N = 16). The primary endpoint was the submucosal dissection speed (mm2/s). The robot arm could apply tissue traction in the desired direction and successfully expose the submucosal plane during submucosal dissection in all lesion locations. The submucosal dissection speed was significantly faster in the R-ESD group than in the C-ESD group (p = 0.005). The blind dissection rate was significantly lower in the R-ESD group (P = 0.000). The robotic arm-assisted traction in ESD enabled a significant improvement in submucosal dissection speed, blind dissection rate which suggests the potential for making ESD easier and enhancing procedural efficiency and safety.

In Vivo Feasibility Test of a New Flexible Ureteroscopic Robotic System, easyUretero, for Renal Stone Retrieval in a Porcine Model.

PURPOSE: Using a new robotic endoscopic platform system developed for retrograde intrarenal surgery (RIRS) called easyUretero (ROEN Surgical Inc.), we evaluated the feasibility and safety of renal stone retrieval in a porcine model. MATERIALS AND METHODS: Six female pigs were used for our in vivo study. First, 0.3-cm-sized phantom stones were inserted into the kidneys of each pig via the ureteral access sheath. Next, renal stone retrieval was attempted using manual RIRS in three pigs and robotic RIRS in three pigs. Three surgeons performed extraction of 10 stones in each session. RESULTS: The mean stone retrieval time by manual RIRS was significantly shorter than that by robotic RIRS (399.9±185.4 sec vs. 1127.6±374.5 sec, p=0.001). In contrast, the questionnaire regarding usability showed high satisfaction in the surgeons' fatigue category for surgeons using robotic RIRS. The radiation exposure dose was also lower in robotic RIRS than in manual RIRS (0.14 µSv vs. 45.5 µSv). Postoperative ureteral injury assessment revealed Grade 0 in manual RIRS cases and Grades 0, 1, and 2 in robotic RIRS cases. CONCLUSION: The easyUretero system is a new robotic RIRS system that was developed in Korea. The results of the present study suggest that using easyUretero for stone retrieval during RIRS is safe and ergonomic.

The usefulness and ergonomics of a new robotic system for flexible ureteroscopy and laser lithotripsy for treating renal stones.

PURPOSE: To investigate the usefulness and ergonomics of a newly developed robotic system for flexible ureteroscopy (easyUretero). MATERIALS AND METHODS: During in vitro testing, six participants performed renal stone removal four times in an artificial kidney-ureter-bladder model. Each participant manipulated a single-use digital flexible ureteroscope (LithoVue) with their hands and the robotic system, sequentially. We compared the task completion times of each participant. The ergonomics of and operational satisfaction with each procedure were assessed by questionnaires. In vivo tests evaluated the operability and safety of the robotic system in two live female pigs. We checked that all the steps of flexible lithotomy for renal stones could be completed individually. RESULTS: The task completion time with the robotic system during in vitro testing was significantly longer than with manual ureteroscopy regardless of the operator's competence level (expert professors: 282.6±92.4 seconds vs. 73.6±43.3 seconds, p<0.001; fellows: 247.5±57.7 seconds vs. 95.8±43.7 seconds, p<0.001; residents: 281.3±111.0 seconds vs. 188.6±138.6 seconds, p<0.001). The residents took more time to remove the upper and mid caliceal stones with the robotic system. The ergonomic evaluation was better for the robotic system, but operational satisfaction was lower, and there was no statistical difference among the groups. In vivo tests showed that all the steps of robotic flexible ureteroscopy could be completed without difficulty. No safety issues were encountered during the procedure. CONCLUSIONS: The robotic system (easyUretero) was ergonomic and safe for flexible ureteroscopy and laser lithotripsy for renal stones.

Feasibility of Laser Lithotripsy for Midsize Stones Using Robotic Retrograde Intrarenal Surgery System easyUretero in a Porcine Model.

Purpose: To test the safety and feasibility of laser lithotripsy for midsize renal stones using a newly developed robotic retrograde intrarenal surgery (RIRS) system (easyUretero) in a porcine model. Materials and Methods: Three urologic surgeons representing three different RIRS experience levels (beginner, intermediate, and expert) participated. Four female pigs (aged 6 months) underwent manual or robotic RIRS. Under general anesthesia, a nephrostomy tract was created ventrally, and calcium stones (diameter, 1.0-1.5 cm) were inserted at renal calices. For manual RIRS, surgeons operated a flexible ureteroscope. For robotic RIRS, the ureteroscope was attached to the robotic slave device. The Auriga XL™ Holmium laser was used for lithotripsy. Lasering and stone retrieval time were measured. Kidneys and ureters were inspected for injury at the end of each session. Results: For the expert, both lasering and stone retrieval by manual RIRS were quicker than by robotic RIRS (22.8 ± 11.0 s/stone vs 234.5 ± 102.5 s/stone, p = 0.02; 41.5 ± 0.5 s/stone vs 79.3 ± 8.1 s/stone, p = 0.02). For the intermediate and beginner, lasering and stone retrieval times were not significantly different between manual and robotic procedures (127.8 ± 93.2 s/stone vs 284.8 ± 112.3 s/stone, p = 0.08; 86.0 ± 30.5 s/stone vs 84.1 ± 21.4 s/stone, p = 0.92). All stones were removed. Grade 1 ureteral and renal injuries occurred in both manual RIRS and robotic RIRS. Conclusions: The laser lithotripsy using the easyUretero robotic system is safe and feasible in a porcine model, even for less-experienced surgeons.

A novel microsurgery robot mechanism with mechanical motion scalability for intraocular and reconstructive surgery.

BACKGROUND: Intraocular surgery and reconstructive surgery are challenging microsurgery procedures that require two types of motion: precise motion and larger motion. To effectively perform the requisite motion using a robot, it is necessary to develop a manipulator that can adjust the scale of motion between precise motion and less precise, yet larger motion. AIMS: In this paper, we propose a novel microsurgery robot using the dual delta structure (DDS) to mechanically scale the motion to seamlessly adjust between precise and larger motion. MATERIALS & METHODS: The DDS forms a lever mechanism that enables the motion scaling at the end-effector using two delta platforms. Seamless scale adjustment enables the robot to effectively perform various surgical moves. RESULTS: A prototype robot system was developed to validate the effectiveness of the DDS. The experiment results in various scale settings validated the scaling mechanism of the DDS. CONCLUSION: Through a graphical simulation and measurement experiment, the robot's precision level and attainable workspace has been confirmed adequate for intraocular and reconstructive surgery.

easyEndo robotic endoscopy system: Development and usability test in a randomized controlled trial with novices and physicians.

BACKGROUND: Some difficulties are common when using endoscopes. Steering is not intuitive, the endoscope weight is a physical burden to physicians and communication problems often occur between operators. METHOD: To overcome these, we developed a robotic endoscopy system and conducted a usability test to compare conventional and robotic manipulation. Nine novices and eighteen physicians participated with the physicians being divided into intermediate and expert groups. The participants performed endoscope insertion into a simulator (physicians) or lesion marking on a testbed (novices) and simulate biopsies. RESULT: Novices completed the tasks faster and with a lower workload when using robotic manipulation, whereas the experts showed the opposite trend. Still, the intermediates showed no significant difference as trials proceeded. Nevertheless, the learning curve analysis showed that the learning rate in all groups is greater for robotic manipulation (21.02% on average) than for conventional manipulation (13.75%) and predicted that physicians can reach manual performance. CONCLUSION: The proposed robotic endoscopy system may allow solo-manipulation using one controller and may be more intuitive and convenient to use than conventional manipulation.

A highly intuitive and ergonomic redundant joint master device for four-degrees of freedom flexible endoscopic surgery robot.

BACKGROUND: Studies have been conducted on slave-specific master devices with a similar kinematic structure to the slave to enhance intuitiveness. However, for the four-degrees of freedom (DOFs) slave of a flexible endoscopic surgery robot, only four DOFs in the master device causes low ergonomic performance. METHODS: To enhance ergonomic performance, a second yaw joint was added as a redundant joint after considering the range of wrist motion and the workspace shape. Three experiments were performed to compare the intuitiveness and ergonomic performance of the proposed device with four-DOFs slave-specific and six-DOFs general-purpose master devices. RESULTS: Significant differences were observed in terms of intuitiveness performance between the slave-specific and the general-purposed master device. On the other hand, there was no significant difference in ergonomic performance between the master devices with redundant joint. CONCLUSIONS: Compared with a general-purpose master device, the proposed one exhibited noticeably improved intuitiveness performance and comparable ergonomic performance.

Effect of backlash hysteresis of surgical tool bending joints on task performance in teleoperated flexible endoscopic robot.

BACKGROUND: The tendon-sheath mechanism provides flexibility but degrades the task performance of the flexible endoscopic robot because of the inherent backlash hysteresis problem. Previous studies have only focused on reducing backlash hysteresis. The goal of this study is to identify the backlash hysteresis criteria of surgical tool bending joints to maintain efficient surgical performance. METHODS: A test platform for a surgical tool has been developed that has initial backlash hysteresis under 5° and can adjust the backlash hysteresis intentionally. Performance variation has been investigated in three bench-top endoscopic tasks in which various backlash hysteresis conditions were intentionally adjusted. RESULTS: A clear drop-off in task performance has been observed when the backlash hysteresis of the bending joints was greater than 10° regardless of the type of task and link length. CONCLUSIONS: The backlash hysteresis of surgical tool bending joints should be reduced to at least 10° to maintain efficient performance in robotic endoscopic surgery.

[The Efficacy of Rebamipide or Ecabet Sodium Supplementation for Helicobacter pylori Eradication Therapy Compared with Quadruple (Concomitant) Regimen].

Background/Aims: Although some previous studies reported that a treatment combined with mucoprotective agent could improve the eradication rate in dual or triple therapy, there are other reports that question the efficacy of combining these drugs in concomitant therapy (CoCTx). The aim of this study was to investigate the effects of rebamipide or ecabet on the Helicobacter pylori (H. pylori) eradication combined with CoCTx. Methods: We retrospectively reviewed the medical records of 277 patients with proven H. pylori infection. They were assigned to one of 3 regimens for 10 days, twice daily: (a) CoCTx (n=118): lansoprazole 30 mg, amoxicillin 1 g, metronidazole 500 mg, and clarithromycin 500 mg; (b) CoCTx+rebamipide (100 mg) (n=85); (c) CoCTx+ecabet (1 g) (n=74). Results: The baseline characteristics were not significantly different. H. pylori eradication rates were 82.2% (97/118) in CoCTx, 90.6% (77/85) in CoCTx+rebamipide, and 89.2% (66/74) in CoCTx+ecabet (p=0.17), which were statistically insignificant. Overall adverse events were more frequently reported in the CoCTx+rebamipide (50.6%. 43/85) and CoCTx+ecabet (44.6%, 33/74) groups than in the CoCTx (32.2%, 38/118) (p = 0.03) group. Drug compliances were not different between three groups (CoCTx: 95.8%, 113/118; CoCT+rebamipide: 92.9%, 79/85; CoCTx+ecabet 98.6%,73/74) (p=0.209). Multivariate analysis showed that the risk of eradication failure was significantly increased with decreased drug compliance (odds ratio 3.52, 95% confidence interval 1.00-12.32; p=0.05). Conclusions: Addition of these mucoprotective agent was not superior to CoCTx alone for eradicating H. pylori infection with frequent adverse events. Rather, drug compliance is the most related factor affecting the eradication rate. Our data suggest the importance of drug compliance over the drugs used.

The Usefulness of Cap-assisted Endoscopic Retrograde Cholangiopancreatography for Cannulation Complicated by a Periampullary Diverticulum.

Endoscopic retrograde cholangiopancreatography (ERCP) is an advanced therapeutic procedure to manage choledocholithiasis and pancreatobiliary malignancy. On occasion, ERCP failure is encountered due to difficulties in cannulation. We assessed the safety and feasibility of cap-assisted ERCP via analyzing cases in which cannulation was complicated by periampullary diverticulum. Between November 2013 and March 2014, ERCP procedures were performed in 346 patients in our tertiary medical center. Among the 73 patients who had a periampullary diverticulum, conventional ERCP failed in 5 patients due to hidden papilla (n=3) or use of tangential approach (n=2). As a rescue method, needle knife fistulotomy and selective biliary cannulation using cap-fitted forward-viewing endoscopy were successfully used in 4 patients without major complications. Based on our experience, cap-fitted forward-viewing endoscopy was relatively easy to measure the exact position of papilla and to perform biliary cannulation properly. Therefore, we recommend using cap-assisted ERCP by forward-viewing endoscopy as a useful and safe alternative to manage patients in whom cannulation is complicated by periampullary diverticulum.

Mediastinal Tuberculous Lymphadenitis Diagnosed by Endosonographic Fine Needle Aspiration.

Isolated mediastinal tuberculous lymphadenitis is clinically rare. Its clinical presentation may mimic an esophageal submucosal tumor by extrinsic compression. A 26-year-old woman was referred to our hospital for an esophageal subepithelial tumor. A 15×10 mm sized subepithelial lesion was found 30 cm from the upper incisors on esophagogastroduodenoscopy. We diagnosed the lesion as a submucosal tumor, and performed endoscopic ultrasonography-guided fine needle aspiration for a pathologic diagnosis. The histologic examination revealed granulomatous inflammation consistent with tuberculosis. We suggest that the use of endoscopic ultrasonography and fine needle aspiration may be helpful in making an early diagnosis and planning for an optimal treatment.

Primary cardiac angiosarcoma: a prolonged response to surgical resection followed by concurrent chemoradiotherapy with docetaxel.

INTRODUCTION: Primary cardiac cancer is a very rare disease, among which primary cardiac angiosarcoma is one of the most frequent type and is characterized by extremely poor prognosis without established optimal treatment. CASE DESCRIPTION: Here we report a case of primary cardiac angiosarcoma with hemorrhagic pericardial effusion who achieved a durable response with tumor excision followed by concurrent chemoradiotherapy with docetaxel. A sixty year old man was presented with dyspnea and was diagnosed with primary cardiac angiosarcoma with hemorrhagic pericardial effusion. After surgical excision of primary tumor with microscopic residual disease followed by concurrent chemoradiotherapy with docetaxel, the patient showed durable response of progression free survival of 12 months. DISCUSSION AND EVALUATION: This case shows benefit of concurrent chemoradiotherapy with taxane. Further investigation of aggressive multimodal treatment strategy is warranted for primary cardiac angiosarcoma with pauci-metastasis even when achievement of complete resection seems unlikely.

Terror management theory in dermatology: skin biopsy influences patient compliance.

A skin biopsy is one of the most frequently performed procedures in the dermatology outpatient clinic, but doctors often do not consider the cognitive impact of the biopsy procedure. Based on "terror management theory," we reasoned that a skin biopsy increases patient compliance by unconsciously stimulating mortality salience. To study this hypothesis, trust toward doctors, authoritarian personality, mood, attitude toward recommendations, and intention to accept recommendations were compared be-tween skin biopsy and non-skin biopsy groups of patients. Eighty-three patients participated in the study, and 78 responses were used for the analysis. The results showed that patients who had a skin biopsy had a more positive attitude toward doctors' recommendations and a higher intention to follow the recommendations. These effects were not moderated by the patient's own personality (patient trust and authoritarian personality). The outcome of this study implies that performing a procedure itself can subliminally influence a patient's attitude toward a doctor's recommendations.