Effects of communication delay in the dual cockpit remote robotic surgery system.

PURPOSE: To evaluate the impact of dual cockpit telesurgery on proctors and operators, and acceptable levels of processing delay for video compression and restoration. METHODS: Eight medical advisors and eight trainee surgeons, one highly skilled per group, performed gastrectomy, rectal resection, cholecystectomy, and bleeding tasks on pigs. Using the Medicaroid surgical robot hinotori™, simulated delay times (0 ms, 50 ms, 100 ms, 150 ms, and 200 ms) were inserted mid-surgery to evaluate the tolerance level. Operative times and dual cockpit switching times were measured subjectively using 5-point scale questionnaires (mSUS [modified System Usability Scale], and Robot Usability Score). RESULTS: No significant difference was observed in operative times between proctors and operators (proctor: p = 0.247, operator: p = 0.608) nor in switching times to the dual cockpit mode (p = 0.248). For each survey setting, proctors tended to give lower ratings to delays of ≥ 150 ms. No marked difference was observed in the operator evaluations. On the postoperative questionnaires, there were no marked differences in the mSUS or Robot Usability Score between the proctors and operators (mSUS: p = 0.779, Robot Usability Score: p = 0.261). CONCLUSION: Telesurgery using a dual cockpit with hinotori™ is practical and has little impact on surgical procedures.

Field experiment of a telesurgery system using a surgical robot with haptic feedback.

PURPOSE: To verify the usefulness of haptic feedback in telesurgery and improve the safety of telerobotic surgery. METHODS: The surgeon's console was installed at two sites (Fukuoka and Beppu; 140 km apart), and the patient cart was installed in Fukuoka. During the experiment, the surgeon was blinded to the haptic feedback levels and asked to grasp the intestinal tract in an animal model. The surgeon then performed the tasks at each location. RESULTS: No marked differences in task accuracy or average grasping force were observed between the surgeon locations. However, the average task completion time was significantly longer, and the system usability scale (SUS) was significantly lower rating for remote operations than for local ones. No marked differences in task accuracy or task completion time were observed between the haptic feedback levels. However, with haptic feedback, the organ was grasped with a significantly weaker force than that without it. Furthermore, with haptic feedback, experienced surgeons in robotic surgery tended to perform an equivalent task with weaker grasping forces than inexperienced surgeons. CONCLUSION: The haptic feedback function is a tool that allows the surgeon to perform surgery with an appropriate grasping force, both on site and remotely. Improved safety is necessary in telesurgery; haptic feedback will thus be an essential technology in robotic telesurgery going forward.

Telesurgery and telesurgical support using a double-surgeon cockpit system allowing manipulation from two locations.

BACKGROUND: Although several studies on telesurgery have been reported globally, a clinically applicable technique has not yet been developed. As part of a telesurgical study series conducted by the Japan Surgical Society, this study describes the first application of a double-surgeon cockpit system to telesurgery. METHODS: Surgeon cockpits were installed at a local site and a remote site 140 km away. Three healthy pigs weighing between 26 and 29 kg were selected for surgery. Non-specialized surgeons performed emergency hemostasis, cholecystectomy, and renal vein ligation with remote assistance using the double-surgeon cockpits and specialized surgeons performed actual telesurgery. Additionally, the impact of adding internet protocol security (IPsec) encryption to the internet protocol-virtual private network (IP-VPN) line on communication was evaluated to address clinical security concerns. RESULTS: The average time required for remote emergency hemostasis with the double-surgeon cockpit system was 10.64 s. A non-specialized surgeon could safely perform cholecystectomy or renal vein ligation with remote assistance. Global Evaluative Assessment of Robotic Skills and System Usability Scale scores were higher for telesurgical support-assisted surgery by a non-specialized surgeon using the double-surgeon cockpits than for telesurgery performed by a specialized surgeon without the double-cockpit system. Adding IPsec encryption to the IP-VPN did not have a significant impact on communication. CONCLUSION: Telesurgical support through our double-surgeon cockpit system is feasible as first step toward clinical telesurgery.

Repetitive pitching decreases the elbow valgus stability provided by the flexor-pronator mass: the effects of repetitive pitching on elbow valgus stability.

BACKGROUND: Baseball pitching induces a large elbow valgus load, stressing the ulnar collateral ligament (UCL). Flexor-pronator mass (FPM) contraction contributes to valgus stability; however, repetitive baseball pitching may weaken the FPM contractile function. The present study investigated the effects of repetitive baseball pitching on the medial valgus stability measured using ultrasonography. We hypothesized that repetitive pitching would decrease elbow valgus stability. METHODS: This was a controlled laboratory study. Fifteen young male baseball players at the collegiate level (age: 23.0 ± 1.4 years) were enrolled. The medial elbow joint space was measured using ultrasonography (B-mode, 12-MHz linear array transducer) in the following three conditions: at rest (unloaded), under 3 kg valgus load (loaded), and under valgus load with maximal grip contraction to activate FPM (loaded-contracted). All measurements were performed before and after the pitching tasks, which comprised five sets of 20 pitches. Two-way repeated-measures analysis of variance was applied to determine changes in the medial elbow joint space. The post hoc test with Bonferroni adjustment was applied to assess the changes within the time and condition. RESULTS: The medial elbow joint space was significantly greater under the loaded than the unloaded and loaded-contracted conditions both before and after pitching (P < .001). In the loaded-contracted condition, the medial elbow joint space significantly increased after repetitive baseball pitching (P < .001). CONCLUSIONS: The results of the present study indicated that repetitive baseball pitching reduced the elbow valgus stability. This reduction could be attributed to the decreased FPM contractile function. Insufficient contraction may increase the tensile load on the UCL with pitching. FPM contraction plays a role in narrowing the medial elbow joint space; however, repetitive baseball pitching reduced the elbow valgus stability. It has been suggested that sufficient rest and recovery of the FPM function are required to reduce the UCL injury risk.

Short-term outcomes of robotic-assisted laparoscopic versus laparoscopic lateral lymph node dissection for advanced lower rectal cancer.

BACKGROUND: Therapeutic strategies to suppress local recurrence, including lateral lymph node metastasis, are important to improve the curability of rectal cancer. The aim of the present study was to clarify the advantages of robotic-assisted laparoscopic lateral lymph node dissection (RALLD), comparing its short-term outcomes with those of laparoscopic lateral lymph node dissection (LLLD). There are some retrospective reports comparing RALLD or LLLD and open lateral lymph node dissection (OLLD), but few reports comparing RALLD and LLND to each other. METHODS: From November 2014 to August 2020, we compared the short-term outcomes in 40 patients who underwent RALLD and 55 patients who underwent LLLD. RESULTS: The total operative time was significantly longer in the RALLD group than in the LLLD group (p < 0.001). However, lateral dissection time was not significantly different between the groups (p = 0.661). The postoperative hospital time was shorter in the RALLD group than in the LLLD group (p < 0.048). No significant differences were identified in the rates of postoperative bleeding, incisional surgical site infection (SSI), organ/space SSI, urinary disfunction, urinary infection, or small bowel obstruction between the groups. However, anastomotic leakage was significantly lower in the RALLD group than in the LLLD group (p = 0.031). CONCLUSIONS: The short-term outcomes of RALLD indicate it is feasible, and RALLD may be a useful modality for lower rectal cancer.

[Short-Term Results of Robot-Assisted Surgery in Patients Undergoing Neoadjuvant Chemotherapy for Rectal Cancer].

The advantages of robot-assisted surgery include: stable deployment of the robotic arm that enables excellent radical cure characteristics and preservation of function; the ability to perform precise surgery even in patients in whom performing laparoscopic surgery is difficult, such as those with pelvic or bulky tumors. However, there have been some reports on such issues as an increase in the incidence of postoperative complications and an increase in postoperative hospital stay in patients who underwent neoadjuvant chemotherapy(NAC); thus, we summarized and are reporting the short-term results of our experience in patients seen in our department to date. A total of 76 patients with rectal cancer who underwent robot-assisted surgery, and short-term postoperative results were compared between patients who underwent neoadjuvant chemotherapy (NAC group)and those who did not undergo neoadjuvant chemotherapy(non-NAC group). Of the 76 patients, 59 (77.6%)were male and 17(22.4%)were female, and 27(35.5%)in the NAC group. In the comparisons between the NAC and non-NAC groups, although the difference in operative time(523.5 vs 317.5 minutes, p<0.01)was significant, there were no significant differences in any of blood loss(59 vs 20g, p=0.22), postoperative hospital stay(14 vs 13 days: p=0.07), and onset of complications that were Clavien-Dindo Grade Ⅲa or higher(2 vs 1 patients, p=0.82). Robot- assisted surgery after NAC for rectal cancer was considered to be safe and very useful.

[Treatment for Laterally Invasive Rectal Cancer with Robot-Assisted Surgery after Preoperative Treatment].

The patient is a 40-year-old male. He was referred to our department because, after a thorough examination, he was diagnosed with rectal cancer. Preoperative imaging showed a tumor in the rectum at the level of the seminal vesicles, and left lateral invasion was suspected. In addition, lymph node metastases in the left lateral area were suspected. We performed a robot-assisted low anterior resection plus bilateral lateral dissection plus covering ileostomy for this patient after neoadjuvant chemotherapy. The operation time was 495 minutes, and the blood loss was 50 g. The histopathological diagnosis was pT3, N3(#263), M0, pStage Ⅲc, PM0, DM0, RM0, R0, Cur A. In Japan, robotic-assisted surgery for rectal cancer has been covered by insurance since April 2018, and in our department, robotic surgery is the first option for any stage or type of surgery for rectal cancer. We believe that the greatest advantages of robotic surgery for rectal cancer are in lateral dissection, ie, the better understanding of how blood vessels and nerves travel around the internal iliac vessels and the associated anatomy of pelvic organs that comes from reliable lateral dissection. We have experienced a case of safe robotic-assisted radical resection of laterally invasive rectal cancer, which is considered to be relatively difficult, and we hereby report the usefulness of the robotic-assisted modality.

Postoperative long­term outcomes of acute normovolemic hemodilution in pancreatic cancer: A propensity score matching analysis.

Acute normovolemic hemodilution (ANH) is a useful intraoperative blood conservation technique. However, the impact on long-term outcomes in pancreatic ductal adenocarcinoma (PDAC) remains unclear. The present study investigated the impact of ANH on long-term outcomes in patients with PDAC undergoing radical surgery. Data from 155 resectable PDAC cases were collected. Patients were categorized according to whether or not they had received intraoperative allogeneic blood transfusion (ABT) or ANH. Postoperative complications, recurrence-free survival (RFS) and disease-specific survival (DSS), before and after propensity score matching (PSM), were compared among patients who did and did not receive ANH. A total of 44 patients (28.4%) were included in the ANH group and 30 patients (19.4%) were included in the ABT group; 81 (52.3%) patients, comprising the standard management (STD) group, received neither ANH nor ABT. The ABT group had the worst prognosis among them. Before PSM, ANH was significantly associated with decreased RFS (P=0.043) and DSS (P=0.029) compared with the STD group before applying Bonferroni correction; however, no significant difference was observed after applying Bonferroni correction. Cox regression analysis identified ANH as an independent prognostic factor for RFS [relative risk (RR), 1.696; P=0.019] and DSS (RR, 1.876; P=0.009). After PSM, the ANH group exhibited less favorable RFS [median survival time (MST), 12.1 vs. 18.1 months; P=0.097] and DSS (MST, 32.1 vs. 50.5 months; P=0.097) compared with the STD group; however, these differences were not statistically significant. In conclusion, while ANH was not as harmful as ABT, it exhibited potentially more negative effects on long-term postoperative outcomes in PDAC than STD.

Reappraisal of telesurgery in the era of high-speed, high-bandwidth, secure communications: Evaluation of surgical performance in local and remote environments.

Aim: Communication and video transmission delays negatively affect telerobotic surgery. Since latency varies by communication environment and robot, to realize remote surgery, both must perform well. This study aims to examine the feasibility of telerobotic surgery by validating the communication environment and local/remote robot operation, using secure commercial lines and newly developed robots. Methods: Hirosaki University and Mutsu General Hospital, 150 km apart, were connected via a Medicaroid surgical robot. Ten surgeons performed a simple task remotely using information encoding and decoding. The required bandwidth, delay time, task completion time, number of errors, and image quality were evaluated. Next, 11 surgeons performed a complex task using gallbladder and intestinal models in local/remote environments; round trip time (RTT), packet loss, time to completion, operator fatigue, operability, and image were observed locally and remotely. Results: Image quality was not so degraded as to affect remote robot operation. Median RTT was 4 msec (2-12), and added delay was 29 msec. There was no significant difference in accuracy or number of errors for cholecystectomy, intestinal suturing, completion time, surgeon fatigue, or image evaluation. Conclusion: The fact that remote surgery succeeded equally to local surgery showed that this system has the necessary elemental technology for widespread social implementation.

Verification of delay time and image compression thresholds for telesurgery.

INTRODUCTION: Telerobotic surgery relies on communication lines, causing delays, and video information requires pre-transmission compression. Such delays and video degradation will continue to be unavoidable making communication conditions verification essential. Understanding the network specification values required for telerobotic surgery entails determining acceptable levels of delay and degradation due to the video compression and restoration processes during surgery. METHODS: The hinotori™ surgical robot from Medicaroid was used. Eight surgeons, skilled in robotic surgery, performed gastrectomy or rectal resection on pigs. Image compression (bitrate: 120, 60, 30, 20, 10 Mbps) was random, changing encoder settings during surgery, and delay times (30, 50, 100, 150 milliseconds) were pseudo-randomly inserted, changing emulator settings. Acceptable video levels were evaluated. Subjective evaluations by surgeons and evaluators regarding image degradation and operability, and objective evaluations of image degradation and operability were given five-point ratings. RESULTS: Regarding delay time, 30 and 50 millisecond periods garnered average ratings of 3.6 and 4.0, respectively, signifying that surgery was feasible. However, at 100 and 150 millisecond, average ratings were 2.9 and 2.3, respectively, indicating surgery was not feasible for the most part in these cases. The average rating for image compression was 4.0 or higher for bitrates of 20, 30, 60, and 120 Mbps, suggesting that surgery is possible even at bitrates as low as 10 Mbps, with an average rating of 4.0. CONCLUSION: In remote robotic surgery using the hinotori™, image compression and delay time are largely acceptable, so surgery can be safely performed.

Construction of redundant communications to enhance safety against communication interruptions during robotic remote surgery.

It is important to ensure the redundancy of communication during remote surgery. The purpose of this study is to construct a communication system that does not affect the operation in the event of a communication failure during telesurgery. The hospitals were connected by two commercial lines, a main line and a backup line, with redundant encoder interfaces. The fiber optic network was constructed using both guaranteed and best-effort lines. The surgical robot used was from Riverfield Inc. During the observation, a random shutdown and restoration process of either line was conducted repeatedly. First, the effects of communication interruption were investigated. Next, we performed a surgical task using an artificial organ model. Finally, 12 experienced surgeons performed operations on actual pigs. Most of the surgeons did not feel the effects of the line interruption and restoration on still and moving images, in artificial organ tasks, and in pig surgery. During all 16 surgeries, a total of 175-line switches were performed, and 15 abnormalities were detected by the surgeons. However, there were no abnormalities that coincided with the line switching. It was possible to construct a system in which communication interruptions would not affect the surgery.

A case of serous cystic neoplasm with tumor growth acceleration leading to extrapancreatic invasion.

Serous cystic neoplasm (SCN) is a potentially malignant and invasive disease. However, there are no established guidelines regarding the surgical management of SCN. Here, we report a case of SCN with jejunal invasion that ultimately required a distal pancreatectomy with partial resection of the jejunum. The patient was a 65-year-old female who was referred to our department after a diagnosis of SCN in the pancreatic tail. CT and MRI showed a 75-mm multifocal cystic mass with calcifications; the splenic vein and left adrenal vein were entrapped within the tumor. Furthermore, the tumor was in contact with the beginning of the jejunum. Finally, she underwent a posterior radical antegrade modular pancreatosplenectomy with a partial wedge-shaped resection of the jejunum. Histological findings indicated serous cystadenoma. In addition, the tumor cells were found to have infiltrated the jejunal muscularis propria in some areas, suggesting that the tumor had malignant potential. Currently, 14 months have passed since surgery and there is no evidence of metastasis or recurrence. Surveillance and the decision to perform surgical resection should be made based on tumor size and growth rate to avoid malignant transformation as well as to provide SCN patients with organ-sparing, less invasive surgery.

Is RNA editing implicated in group II intron survival in the angiosperm mitochondrial genome?

Introns may be considered as optional because they are removed from mRNA molecules, but introns are fairly preserved for unknown reasons. Previously, the mitochondrial rps3 gene of sugar beet ( Beta vulgaris L., Caryophyllales) was shown to represent a unique example of an intron loss. We have determined the distribution of the rps3 intron in 19 Caryophyllalean species. The intron was absent from the Amaranthaceae and the Achatocarpaceae. In the Caryophyllaceae, Dianthus japonicus rps3 was pseudogenized, but the intronic sequence was retained. Intact intron-bearing rps3 copies were cloned from Portulaca grandiflora and Myrtillocactus geometrizans , members of the sister clade of the Amaranthaceae-Achatocarpaceae-Caryophyllaceae clade. Most of the C-to-U RNA-editing sites in P. grandiflora and M. geometrizans rps3 transcripts were homologous in the two species, as well as in the sugar beet rps3, which, unlike the other 12 rps3 transcripts, lacks editing in the exonic regions around the intron. Provided that the loss of editing preceded the loss of rps3 intron, it appears conceivable that a requirement for editing could have prevented the loss of group II introns retained in angiosperm mitochondrial genomes. This interpretation is an alternative to the conventional one that views the loss of editing as a mere trace of RNA-mediated gene conversion.

[A case of neuroleptic malignant syndrome caused by discontinuation of psychotropic drugs].

A 71-year-old woman with schizophrenia and diabetes discontinued psychotropic drugs due to right purulent knee bursitis. Five days after discontinuation, she presented with a fever of >40°C, severe disturbance of consciousness, lead-pipe muscle rigidity, tachypnea, and hypertension. She was diagnosed with neuroleptic malignant syndrome (NMS) induced by the discontinuation of psychotropic drugs. The patient's symptoms improved after dantrolene administration and systemic management. We investigated the clinical characteristics of cases with NMS induced by the discontinuation of psychotropic drugs reported in Japan, including the present case. When psychotropic drugs are discontinued, patients should be monitored for signs of NMS. Strict management of early onset NMS is needed to prevent the condition from worsening.

Evolutionary aspects of a unique internal mitochondrial targeting signal in nuclear-migrated rps19 of sugar beet (Beta vulgaris L.).

The endosymbiotic theory postulates that many genes migrated from endosymbionts to the nuclear genomes of their hosts. Some migrated genes lack presequences directing proteins to mitochondria, and their mitochondrial targeting signals appear to be inscribed in the core coding regions as internal targeting signals (ITSs). ITSs may have evolved after sequence transfer to nuclei or ITSs may have pre-existed before sequence transfer. Here, we report the molecular cloning of a sugar beet gene for ribosomal protein S19 (Rps19; the first letter is capitalized when the gene is a nuclear gene). We show that sugar beet Rps19 (BvRps19) is an ITS-type gene. Based on amino-acid sequence comparison, dicotyledonous rps19s (the first letter is lower-cased when the gene is a mitochondrial gene), such as tobacco rps19 (Ntrps19), resemble an ancestral form of BvRps19. We investigated whether differences in amino-acid sequences between BvRps19 and Ntrps19 were involved in ITS evolution. Analyses of the intracellular localization of chimaeric GFP-fusion proteins that were transiently expressed in Welsh onion cells showed that Ntrps19-gfp was not localized in mitochondria. When several BvRps19-type amino acid substitutions, none of which was seen in any other angiosperm rps19, were introduced into Ntrps19-gfp, the modified Ntrps19-gfp became localized in mitochondria, supporting the notion that an ITS in BvRps19 evolved following sequence transfer to nuclei. Not all of these substitutions were seen in other ITS-type Rps19s, suggesting that the ITSs of Rps19 are diverse.