6 Annual th

MIRA Congress
“Robotics Surgery Marathon: Clinical Practice, Education & the Simulation Olympics”
May 11-13, 2011 Athens, Greece Hilton Athens

MIRA President: Jacques Hubert, MD Participation from:

Program Chair: Ivo Broeders, MD The Clinical Robotic Surgery Association (CRSA)
Congress President: Konstantinos Konstantinidis, MD The Society of Robotics Surgery (SRS)
Program Co-Chair: Savas Hiridis, MD The Hellenic Scientific Society of Robotic Surgery
New Technology Demonstrations at the
Intuitive Surgical Booth
Single-Site™ Instrumentation
for the da Vinci® Si™ Surgical System

Hands on demonstrations and 1st clinical experience footage

This product has received CE mark but is not cleared by the FDA

The da Vinci Skills Simulator™

Skills practice in an immersive virtual environment

Schedule subject to change. While clinical studies support the use of the da Vinci Surgical System as an effective tool for minimally invasive surgery, individual results may vary. Before performing any clinical
procedure utilizing the System, physicians are responsible for receiving sufficient training and proctoring to ensure that they have the requisite training, skill, and experience necessary to protect the health and
safety of the patient. For technical information, including full cautions and warnings on using the da Vinci System, please refer to the System User Manual. Read all instructions carefully. Failure to properly follow
instructions, notes, cautions, warnings, and danger messages associated with this equipment may lead to serious injury or complications for the patient. © 2011 Intuitive Surgical. All rights reserved. Intuitive, Intui-
tive Surgical, da Vinci, da Vinci S HD, da Vinci Si, InSite, TilePro and EndoWrist are trademarks or registered trademarks of Intuitive Surgical. All other product names are trademarks or registered trademarks of their
respective holders. PN 874434 Rev A 4/11
 Welcome
On behalf of the organizing committee of the MIRA 2011
Congress, it is my pleasure to welcome you to the 6th International
Congress on Robotic Surgery.
The purpose of the 6th International Congress is to bring together
surgeons of all specialties, internists, basic science and clinical
researchers and engineers from around the world to discuss the
state-of-the-art in robotic surgical techniques and to set the
directions and trends for its future improvements.
We are delighted that most of the world leaders in the field will be
present. This will be a timely meeting to set or reset the goals of
Robotic Surgical Clinical Programs for future years.
It will also be a unique opportunity for students, residents and interns
to learn about robotic surgery and interact with world experts.
A variety of social activities will give you the opportunity to meet
friends, enjoy the traditional Greek music, food, dancing and
hospitality. The historical city of Athens, the birthplace of Socrates
and Plato, the home of philosophy, democracy and culture, is an
ideal setting for providing such an atmosphere and environment.
We are looking forward to see you all in Greece for a glorious 2011
meeting!
K.M.Konstantinidis, MD, PhD, FACS,
The MIRA 2011 Congress President
GENERAL INFORMATION
COURSE DESCRIPTION
The 6th International Congress will feature state of the art lectures,
4 Post-Graduate Courses, a Business Class Course, and internationally
renowned faculty. This activity offers an extensive update on the
advancements within minimally invasive robotic procedures.
OBJECTIVES
At the conclusion of this activity, participants should be able to:
• Educate in detail the new robotic surgical teams in well-established
procedures in General Surgery, Urology, Gynecology and Cardiothoracic
during the Postgraduate Course sessions.
• Address current applications of robotics in various specialties of surgery and
assess clinical efficiency and safety.
• Present latest innovations of the technology with new instrumentation, better
ergonomics and different concepts such as single-port robotics.
• Introduce future trends in research level such as novel robotic systems,
microrobotics, intraoperative navigation and augmented reality and
immunofluorecence lymph node visualization.
TARGET AUDIENCE
The target audience for this activity includes: surgeons, internists,
radiologists, engineers and computer scientists who are interested in
robotics, telerobotics, telepresences, teleconferencing and telementoring.

CONTACT INFORMATION
MIRA: 11300 West Olympic Blvd., Ste. 600, Los Angeles, CA, USA 90064
Phone: +1.310.424.3353, ext. 125 | Email: Maribeth@mirasurgery.org
SPEAKER PREP/
REG HOURS Ikaria/Middle Lobby (Convention Level) OFFICIAL CONGRESS HOTEL INFORMATION
Wednesday, May 11, 2011 10:00am-7:00pm Hilton Athens: 46 Vassilissis Sofias Avenue, Athens, Greece 11528
Thursday, May 12, 2011 7:30am-8:00pm Phone: +30.210.7281000 | Fax: +30.210.7281111
Friday, May 13, 2011 7:30am-8:00pm
WHY JOIN MIRA?
EXHIBIT & POSTER HOURS Terpsichore D/Erato • Interaction with leaders on the cutting edge of minimally invasive robotic
Wednesday, May 11, 2011 7:00pm-8:30pm interventions and techniques.
Welcome Reception in Exhibit Hall
• An international membership dedicated to providing the best diagnostic and
Thursday, May 12, 2011 10:30am-4:30pm
therapeutic care possible, even in distant and remote places.
Friday, May 13, 2011 9:30am-4:00pm
• The sharing of knowledge with a multidisciplinary group of professionals,
Make sure to sign up for your chance to compete in the Robotic including surgeons, internists, radiologists, engineers and computer scientists
Olympics Contest! Sign up sheets can be found at the registration desk and who are developing and using minimally invasive robotics.
participants are encouraged to compete throughout the Congress.The top 8 • The opportunity to contribute to innovations, integration and implementation
finalists will compete for the Gold Medal on Friday, May 13, 2011! of future developments in areas such as NOTES and Solo Surgery.
• An opportunity to contribute in organizing the training and establishing
requirements for credentialing.
TABLE OF CONTENTS • A subscription to The International Journal of Medical Robotics and
General Information 1 Computer Assisted Surgery journal included in the annual membership dues.
About Athens, Greece 2 • The advantage to attend our meetings at the lower member registration fees.
Meeting Leadership & Invited Faculty 2
Please visit www.mirasurgery.org/membership.php to become a
MIRA Board Members 4
member today!
Meeting Committees 4
Floorplan 5 ABOUT MIRA
Exhibitors 5 MIRA was founded under the sky of Tuscany, Italy, in June 2004,
Schedule-at-a-Glance 6 as a result of a discussion among experts, sharing their experiences,
Scientific Program 7 problems, technical details, and perspectives.
Oral Abstracts 13
Video Abstracts 28 MIRA is a multidisciplinary association that provides multi-specialty
Poster List 32 forums to present new advances and clinical outcomes in all aspects of
Poster Abstracts 36 robotic surgery.
MIRA Membership Application 61
www.mirasurgery.org 1
about Meeting Leadership & Invited Faculty
ATHENS, GREECE
MEETING LEADERSHIP
GENERAL INFORMATION
Athens is renowned all over the world for its
millenary history, for spreading art, culture, science
and philosophy throughout, thus being the cradle
of modern western civilization. The city presents
a unique combination of the ancient history
and modern world, and offers an unforgettable
Mediterranean experience to all its visitors. The ideal MIRA President: Program Chair:
climate, the great hospitality, the rich transportation Jacques Hubert, MD Ivo Broeders, MD
network, the unique combination between
business and pleasure, the fully renovated meeting
infrastructure, as well as the great variety of cultural
and entertainment options can be a few of the city’s
advantages. Actually, Athens has a proud tradition of
hosting great medical and scientific events. Congress President:
Konstantinos Program Co-Chair:
GETTING TO THE CONGRESS HOTEL Konstandtinidis, MD Savas Hiridis, MD
The airport is located 33 km southeast of Athens and is
easily accessible via Attiki Odos, a six-lane motorway
(the Athens City Ring Road). Public transportation to INVITED FACULTY
Athens and the Port of Piraeus is provided by express Abdulrahman Albassam, MD Gunjal Garg
airport bus connections on a 24-hour basis, while a King Khalid University Hospital Wayne State University, Detroit Medical Center
direct Metro line connects the airport with the city Mehran Anvari, MD Changqing Gao, MD
centre (Syntagma square) in 27 minutes. Professor of Surgery, Chair in Minimally PLA General Hospital
Invasive Surgery & Surgical Innovation, Professor Evangelos Georgiou, MD,
The Congress hotel, Hilton Athens, is also
McMaster University, Canada PhD
connected to the airport via the blue line and
is located close to Evangelismos station. Vassilis Apostolopoulos, PhD Athens University Medical School, Athens,
Athens Medical Group, CEO, Athens, Greece Greece
A taxi ride from the airport to the city centre and
the Congress venue costs between 26-40 Euros. Nikos Aspragathos Farid Gharagozloo, MD
Professor, University of Patras, Patras, Greece Institute of Thoracic and Cardiovascular
Duration approximately 40 minutes. Masoud Azodi, MD Surgery, George Washington University
Yale-New Haven Hospital Medical Center, Washington, DC, USA
Climate: Temperate, mild winter, warm, dry
summer. The average daytime temperature in May Scott J Belsley, MD George Giannopoulos, MD
can vary between 12°C and 20°C. St. Luke’s-Roosevelt Hospital Center Yonsei University College of Medicine
Language: The native language is Modern Greek. Nikolaos Bonaros Piero Giulianotti, MD, FACS
English is widely spoken as a second language by Innsbruck Medical University Professor of Surgery, Chief, Division of
Minimally Invasive, General & Robotic
the majority of Greeks, while French and German Johannes Bonatti, MD Surgery, University of Illinois at Chicago,
are also spoken at a good extent. University of Maryland, Baltimore, MD, USA Chicago, IL, USA
Time: Greece is two hours ahead of Greenwich Mean Prof. Ivo A.M.J. Broeders MD, Prof. Grigor Gorchev, MD, PhD,
Time GMT+2 PhD DSc
University Twente,Technical Medicine, Medical University Pleven, Pieven, Bulgaria
Greece 12:00 – London 10:00 – New York 05:00 –
Meander Medical Center Amersfoort,
Sydney 20:00 The Netherlands Monika E. Hagen, MD, MBA
Division of Digestive Surgery, University
Electricity: The electricity current in Greece Vasiliki Chatzirafail Hospital Geneva, Geneva, Switzerland, &
is 220v, 50Hz and the socket type is Europena Director of Gyn Department, Euroclic, Intuitive Surgical, Sunnyvale, CA, USA
Standard. Athens, Greece
Dong-Seok Han, MD
Smoking Policy: Starting from July 1st 2009 Pericles-J Chrysoheris, MD Department of Surgery, Cancer Research
smoking is prohibited by the law at all indoor Athens Medical Center, Athens, Greece Institute, Seoul National University, College
public areas in Greece. Professor Woong Youn Chung of Medicine
Health: Emergency treatment is free to all – Department of Surgery, Yonsei University Georgios E. Hilaris, MD, FACOG
natives and visitors alike – in public hospitals. There College of Medicine, Seoul, Korea Department of Laparoscopic & Robotic
are more doctors per person in Greece than in Michael A Conditt, PhD Surgery and Gynecologic Oncology, Hygeia
most other counties in the European Union. MAKO Surgical Corp and IASO Medical Centers, Athens, Greece
Adjunct Clinical Instructor of Obstetrics and
Currency: Greece is a full member of the Jose Manuel Fort, PhD Gynecology, Stanford University, Palo Alto,
European Union since 1981, and its currency is Universitary Hospital Vall d’Hebron CA, USA
the Euro (€). All major credit cards are widely Taryn N Gallo, MD
accepted in Greece. Yale New Haven Health/Bridgeport Hospital
2 6 TH ANNUAL MIRA CONGRESS May 11-13, 2011
 Savas C. Hiridis MD, MSc
Athens Medical Center, Athens, Greece
Petros C Hiridis, MD
Athens Medical Center, Athens, Greece
Abolfazl Hosseini, MD, PhD
Dept of Urology, Karolinska University Hospital
Stockholm, Sweden
Jacques Hubert, MD
Professor of Urology, Head of the Urology
Department, University Hospital of Nancy
Chu Nancy - Brabois, Nancy, France
N Hubert, MD
Urology Dept., CHU de Nancy-Brabois
Woo Jin Hyung, MD PhD
Yonsei University College of Medicine
Bob Kiaii, MD
London, Ontario Canada
C.E. Iselin, MD
Professor and Chief, Urology Clinic, Geneva
University Hospital, Geneva, Switzerland
Sang-Wook Kang, MD
Yonsei University College of Medicine
Vasilis Kapetanakis, MD
Mayo Clinic, IASO Medical Centers'
Hyoung-Il Kim, MD
Department of Surgery, Institute of Gastroenterology,
and Cancer Metastasis Research Center, Yonsei
University College of Medicine
Jin C. Kim, MD
University of Ulsan College of Medicine and Asan
Medical Center
Se-Heon Kim, MD
Yonsei University College of Medicine, Seoul, Korea
Konstantinos M. Konstantinidis, MD,
PhD, FACS
Athens Medical Center, Athens, Greece
N Kuperij, BSc
University of Twente, Department of Technical
Medicine, University of Twente
Apostolos P. Labanaris, MD, PhD
Department of Urology and Pediatric Urology, Prostate
Center Northwest, St. Antonius Medical Center
Professor Georges Lawson, MD
ORL- Head & Neck Surgery, Clinique Universitaires
UCL de Mont Godine, Yvoir, Belgium
Jandee Lee, MD, PhD
Yonsei University College of Medicine
Sohee Lee
Department of Surgery, Yonsei University Health System
Eric J Lehr, MD, PhD
University of Maryland School of Medicine
Medizinische Universität Innsbruck
Mario M Leitao, MD
Memorial Sloan-Kettering Cancer Center
Fiona Lindo, MD
Yale New Haven Health/Bridgeport Hospital
www.mirasurgery.org
Dimitrios Linos, MD, FACS
Consultant in Surgery Massachusetts General Hospital,
Lecturer on Surgery Harvard Medical School, Director
of Surgery, Hygeia Hospital, Athens, Greece
Michael Litos, MD, PhD, MRCOG
Euroclinic, Athens, Greece
Fabrizio Luca, MD
European Institute of Oncology, Milano, Italy
John Lymer, PEng
Chief Engineer, MDA, Brampton ON Canada
John J. Meehan, MD, FACS
Co-Director, Seattle Children’s International Robotic
Surgery Center, Seattle Children’s Hospital
University of Washington, Seattle, Washington, USA
Jonathan J Melquist, MD
Stony Brook University Medical Center
John S. Missanelli, DO
Sharp Grossmont Hospital, La Mesa, CA, USA
Konstantinos Myrillas, MRCOG
Athens, Greece
Zbigniew Nawrat, MD
Foudation of Cardiac Suregry Development
Vincent Obias, MD
George Washington University
Mona Orady, MD
Division of Minimally Invasive Gynecology and
Robotic Surgery, Department of Obstetrics,
Gynecology, and Women’s Health, Henry Ford
Health System
Elena Ortiz Oshiro, MD, PhD
Hospital Clinico San Carlos, Universidad
Complutense de Madrid
Emanuel Panagiotou, MD, FACS
Diplomate of the American Board of Urology
Director Urology clinic, Robotic Urology, Hygeia
Hospital, Athens, Greece
Aristotelis Panos, MD, PhD, FECTS
3rd Clinic for Cardiac Surgery, Hygeia Hospital
Athens, Greece
Harilaos Pappis, MD, PhD, FACS
Head 3rd Surgical Dept. Hygeia Hospital
Athens, Greece
Jae Hyun Park
University of Ulsan College of Medicine
C. Perrenot, MD
Urology Dept & IADI, CHU Nancy-Brabois
Alessio Pigazzi, MD, PhD
City of Hope National Medical Center, Dept of
General Oncologic Surgery, Duarte, CA
Irinel Popescu, MD, PhD, FACS
Fundeni Institute of Digestive Diseases and Liver
Transplantation
Vassilis Poulakis, MD, PhD, FEBU
Associate Professor at the University of Frankfurt, Germany
Urology Clinic of Doctors’ Hospital, Athens, Greece
Francois Pugin, MD
University Hospitals Geneva
Ryan Rhodes
Vice-President, Clinical Marketing,
Intuitive Surgical, Inc, Sunnyvale, CA
Emilio Ruiz Morales
Eur Ing- Head, ALF-X Surgical Robotics Department
SOFAR S.p.A., Milan, Italy
Richard M. Satava, MD
Professor, Department of Surgery, University of
Washington Medical Center, Seattle, Washington, USA
Dan-Arin Silasi, MD
Yale New Haven Health/Bridgeport Hospital
Giuseppe Spinoglio, MD
Division of Oncologic General Surgery,
General Hospital, Alessandria, Italy
Michael Stark, MD, President
New European Surgical Academy, Berlin, Germany
Maarten Steinbuch, Prof. Dr.
Eindhoven University of Technology, The Netherlands
Chung Ngai Tang, MBBS FRCS
Department of Surgery, Pamela Youde Nethersole
Eastern Hospital
Eugene P. Toy, MD
University of Rochester
N. van der Stap, BS
University of Twente, Meander Medical Center
Prof. Dr. Richard Van Hillegersberg
Department of Surgery, University Medical Utrecht
The Netherlands
Catalin Vasilescu, Assoc. Prof., PhD
Fundeni Institute of Digestive Disease and Liver
Transplantation
Roy Verhage, MD
University Medical Center Utrecht
C. Waked, MD PhD
Dept. of Urology and Nephrology,
CHU Nancy-Brabois
Professor Paul Alan Wetter
Chairman, Society of Laparoendoscopic Surgeons,
Professor Emeritus, University of Miami School of
Medicine, Miami, Florida, USAEric B. Wilson, MD
UTHealth Medical School, Houston, TX, USA
Yanghee Woo, MD
Department of Surgery, Robot and Minimally Invasive
Surgery Center, Yonsei University College of Medicine
Hong Man Yoon, MD
Research Institute and Hospital, National Cancer
Center
Ningxin Zhou
Institute of Hepatobiliary & Gastrointestinal
Diseases, PLA Second Artillery General Hospital
3
meeting leadership Meeting committees
MIRA Board Members
MIRA PROGRAM LOCAL SCIENTIFIC LOCAL MEDICAL
Mehran Anvari, MD COMMITTEE COMMITTEE STUDENT
Past-President, Hamilton, Ontario, Canada Ivo Broeders K. Anastasakou COMMITTEE
Garth Ballantyne, MD Savas Hiridis N. Andriopoulos A. Bogiatzopoulou
Past-President, Hackensack, NJ, USA Santiago Horgan N. Aspragathos K. Dakis
Robert Kiaii G. Basdanis J. Dimovelis
Johannes Bonatti, MD George Lawson Ch. Charitopoulos A. Dovolou
President-Elect, Baltimore, MD, USA Ch. Georgakopoulos
Javier Magrina G. Chilaris
Ivo A. M. J. Broeders, MD Marc Margolis Th. Diamandis K. Imbrialos
Vice President, Utrecht,The Netherlands John Meehan Ch. Efthimiadis Th. Katsichtis
Arnold Byers, MD Dmitry Oleynikov P. Feretos S. Korre
Board Member, Hackensack, NJ, USA Alessio Pigazzi P. Gavriil A. Koutis
Ash Tewari E. Georgiou A. Michalinos
James Fleshman, MD
V. Hadjirafail K. Mitsakou
Board Member, St. Louis, MI, USA LOCAL V. Kapetanakis K. Mpananis
Changqing Gao, MD ORGANIZING K. A. Konstantinidis I. Pentara
Board Member, Beijing, China COMMITTEE D. Koutsouris K. Psatha
Farid Gharagozloo, MD F. Antonakopoulos D. Linos M. Sideris
Board Member,Washington, DC, USA P. Chrysoheris K. Myrillas I. Tsiakas
M. Georgiou N. Nikiteas A. Tzeortzopoulou
Indi Gill, MD P. Hiridis
Board Member, Los Angeles, CA, USA E. Panagiotou S. Vasiliou
D. Mousiolis A. Panos A. Vlachou
Santiago Horgan, MD Ch. Pappis A. Zouridis
Past-President, San Diego, CA, USA N. Pardalidis
Jacques Hubert, MD G. Pistofidis
President, Nancy, France Ach. Ploumidis
Woo Jin Hyung, MD Ant. Ploumidis
Board Member, Seoul, Korea V. Poulakis
G. Sambalis
Camran Nezhat, MD
D. Tsakagiannis
Board Member, Palo Alto, CA, USA
Ch. Tsigris
Dmitry Olyenikov, MD K. Tzafestas
Board Member, Omaha, NE, USA M. Vorias
Sonia Ramamoorthy, MD A. Xiarchos
Treasurer, La Jolla, CA, USA G. K. Zografos
Richard Satava, MD G. N. Zografos
Board Member, Seattle,WA, USA
Ash Tewari, MD
Secretary, NewYork, NY, USA

MIRA 2011 MEETING CORPORATE SUPPORTERS

Diamond Donor Gold Donor Silver Donor

Meeting Sponsors
Postgraduate Course Sponsor

4 6 TH ANNUAL MIRA CONGRESS May 11-13, 2011

 HOTEL FLOORPLAN MIRA 2011
EXHIBITORS
CONVENTION LEVEL

POOL LEVEL

www.mirasurgery.org 5
Schedule-at-a-Glance Faculty subject to change
WEDNESDAY, MAY 11, 2011
10:00am-6:00pm Registration/Speaker Prep Middle Lobby (Convention Level)
12:00pm-6:00pm Postgraduate Courses
1) Urology: Radical Prostatectomy, Cystectomy and Partial Nephrectomy Santorini 1
2) Gynecology: Complex Surgery for Benign and Malignant Gynecologic Disorders Thalia 4
3) Colo-Rectal Surgery: Robotic (Para)rectal Dissection Santorini 2
4) Cardio-Thoracic Surgery: Malignant and Benign Disorders of Lung and Esophagus Thalia 3
3:00pm-7:00pm Business Class Meeting Terpsichore ABC
7:00pm-8:30pm Welcome Reception in Exhibit Hall Terpsichore D/Erato
THURSDAY, MAY 12, 2011
7:30am Registration/Coffee & Tea Middle Lobby (Convention Level)
8:30am-11:20am Plenary Session Terpsichore ABC
8:30am Welcome/Presidential Address – Jacques Hubert, MD
9:00am Keynote Lecture: From Hippocrates to da Vinci – Konstantinos Konstantinidis, MD
9:30am Advances in Clinical Robotics: The Year 2010-2011 Part I
11:20am Coffee & Tea Break in Exhibit Hall Terpshichore D/Erato
11:40am From Experiment to Clinic: What’s Coming? Terpshichore ABC
1:20pm Lunch on own/Exhibits & Posters Open Terpsichore D/Erato
2:00pm-4:00pm Concurrent Sessions
SS01: General Surgery I Terpsichore ABC
SS02: General Surgery II Thalia 3
SS03: Urology (2:00pm-3:00pm)/SS04: Cardio-Thoracic (3:00pm-4:00pm) Thalia 4
4:00pm Coffee& Tea Break in Exhibit Hall Terpsichore D/Erato
4:30pm-5:30pm Concurrent Sessions and Video Sessions
SS05: General Surgery Terpsichore ABC
SS06: Gynecology Thalia 3
SS07: Urology/Thoracic/Pediatric/Miscellaneous Thalia 4
5:30pm-6:00pm Keynote Lecture: Intuitive Surgical and the Future of Robotic Surgery
Ryan Rhodes, Vice-President, Clinical Marketing, Intuitive Surgical, Inc
6:00pm Grand Opening Ceremony
Congress President: Dr. Konstantinidis
Welcome message from governmental and academic authorities.
8:30pm Gala Dinner: Dreams Asteras Seaside
Shuttles will depart from the Hilton Athens at 8:00pm. Shuttles will be available as of 10:00pm to bring participants back to the hotel.
Please note that guests are welcome for a fee. Space is limited so please visit registration for more information and tickets.
FRIDAY, MAY 13, 2011
7:30am Registration/Coffee & Tea Outside Terpsichore ABC
8:00am-8:30pm MIRA Business Meeting (All Members Welcome) Terpsichore ABC
8:30am-10:00am Robotics in Space Terpsichore ABC
10:00am Coffee& Tea Break in Exhibit Hall Terpsichore D/Erato
10:15am-11:15am Single Incision Symposium Terpsichore ABC
11:15am-1:30pm Advances in Clinical Robotics: The Year 2010-2011 Part II Terpsichore ABC
1:30pm-2:30pm Lunch on own Exhibits & Posters Open Terpsichore D/Erato
2:30pm-3:30pm Concurrent Sessions
SS08: Gynecology Terpsichore ABC
SS09: Pediatric Surgery and TORS Thalia 3
SS10: Novel Applications - Simulation, Research & Miscellaneous Thalia 4
3:30pm Coffee& Tea Break in Exhibit Hall Terpsichore D/Erato
3:45pm-5:00pm Plenary Best Abstract and Video Session Terpsichore ABC
5:00pm Coffee & Tea Break Terpsichore D/Erato
5:15pm-6:15pm The Robotic Olympic Live Contest Terpsichore ABC
6:15pm-7:00pm Robotics in Surgery: Where Are We Heading? – Richard Satava, MD Terpsichore ABC
7:00pm-8:00pm Closing Lectures: Past President, President and Closing Remarks from Congress President Terpsichore ABC
8:00pm Congress Adjourned
6 6 TH ANNUAL MIRA CONGRESS May 11-13, 2011
 SCIENTIFIC PROGRAM
WEDNESDAY, MAY 11, 2011
12:00pm-6:00pm POSTGRADUATE COURSES
1) Urology: Radical Prostatectomy, Cystectomy and Partial Nephrectomy /Santorini 1 Santorini 1
Chair: Jacques Hubert, MD
Co-Chairs: A.Hosseini, MD & Christope Iselin
12:00pm-12:20pm Introduction: Robotics in Urology – Jacques Hubert, MD
12:20pm-1:20pm Robotic Pelvic Surgery: Principles – Christophe Iselin, E. Panagiotou, MD, A. Hosseini, & N. Pardalidis, MD
1:20pm-1:40pm Coffee & Tea Break
1:40pm-2:40pm Robotic Radical Prostatectomy – Christophe Iselin, MD & Emannouel Panagiotou, MD
2:40pm-3:40pm Robotic Radical Cystectomy with Neobladder Formations – Abbi Hosseini, MD & Nikolaos P. Pardalidis, MD
3:40pm-4:00pm Coffee & Tea Break
4:00pm-5:40pm Renal Surgery UPJ – Christophe Iselin & Nikolaos Pardalidis, MD
Radical, Partial Nephrectomy & Donor Nephrectomy – Jacques Hubert, MD
5:40pm-6:00pm Questions & Discussion

2) Gynecology: Complex Surgery for Benign and Malignant Gynecologic Disorders Thalia 4
Chair: Grigor Gorchev, MD, PhD, DSc
Co-Chair: Konstantinos Myrillas, MD
12:00pm-12:20pm Introduction: State of the Art in Robotic Gynecology – Petros Hirides, MD, PhD
12:20pm-1:20pm Robotic Total Hysterectomy and Lymph Node Harvesting – Grigor Gorchev, MD, PhD, DSc
1:20pm-1:40pm Coffee & Tea Break
1:40pm-2:40pm Robotic Excision of Uterine Fibromas – Konstantinos Myrillas, MD
2:40pm-3:40pm Robotic-Assisted Laparoscopic Sacrocolpopexy and Cervicosacropexy – David M. Kimble, MD
3:40pm-4:00pm Coffee & Tea Break
4:00pm-4:50pm Robotic Tubal & Ovarian Procedures – Konstantinos Myrillas, MD
4:50pm-5:40pm Colpoteres Suspension Procedure – John S. Missanelli, DO
5:40pm-6:00pm Questions & Discussion

3) Colo-Rectal Surgery: Robotic (Para)rectal Dissection Santorini 2

Chair: Fabrizio Luca, MD
Co-Chair: Pericles-J Chrysoheris, MD
12:00pm-12:20pm Introduction: State of the Art in Robotic Colorectal Surgery – Pericles-J Chrysoheris, MD
12:20pm-12:40pm Robotic Right Colectomy for Cancer – Giuseppe Spinoglio, MD
12:40pm-1:00pm Robotic Left Colectomy for Cancer – Savas Hiridis, MD
1:00pm-1:10pm Panel Discussion – Faculty
1:10pm-1:50pm Coffee & Tea Break
1:50pm-2:10pm Robotic Anterior Resection of the Rectum: Hybrid Technique. Patient Positioning,
Trocar Placement, Procedure Step by Step – Alessio Pigazzi, MD
2:10pm -2:30pm Robotic Anterior Resection of the Rectum: Full Robotic Single Position Technique.
Patient Positioning, Trocar Placement, Procedure Step by Step – Fabrizio Luca, MD
2:30pm-2:40pm Panel Discussion – Faculty
2:40pm-3:10pm Robotic Procedures for Rectal Cancer – Alessio Pigazzi, MD
3:10pm-3:30pm Robotic Total Mesorectal Excision: The Key Points for Autonomic Nerve Preservation – Fabrizio Luca, MD
3:30pm-3:40pm Panel Discussion – Faculty
3:40pm-4:00pm Single port colectomy – Vincent Obias, MD
4:00pm-4:20pm Coffee & Tea Break
4:20pm-4:40pm Robotic Treatment of Benign Colo-Rectal Diseases – Vincent Obias, MD
4:40pm-5:00pm Robotic Colorectal Oncology Concerns – Alessio Pigazzi, MD
5:00pm-5:30pm Questions & Discussion

www.mirasurgery.org 7
SCIENTIFIC PROGRAM
4) Cardio-Thoracic Surgery: Malignant and Benign Disorders of Lung and Esophagus Thalia 3
Chair: Farid Gharagozloo, MD
Co-Chair: Richard van Hiiligersberg, MD
12:00pm-12:40pm Robotically Assisted Coronary Artery Bypass Grafting – Johannes Bonatti, MD
12:40pm-1:20pm Robotic-Assisted Thoracoscopic Lobectomy for Lung Cancer – Farid Gharagozloo, MD
1:20pm-1:40pm Coffee & Tea Break
1:40pm-2:40pm Robot-Assisted Thoracoscopic Esophagectomy for Cancer – Richard van Hiiligersberg, MD
2:40pm-3:40pm Robot-Assisted Thoracoscopic Excision of Mediastinal Tumors – Farid Gharagozloo, MD
3:40pm-4:00pm Coffee & Tea Break
4:00pm-5:00pm Advances in Robotic Cardiac Surgery – Bob Kiaii, MD
5:00pm-5:30pm Questions & Discussion
Postgraduate courses are supported by a grant from Athens Medical Centre.

3:00pm-7:00pm BUSINESS CLASS MEETING Terpsichore ABC

Moderators: Ivo Broeders, MD & Ryan Rhodes
3:00pm-3:30pm Launching A Da Vinci Program: A Multi-Stakeholder Process – Ivo Broders, MD
3:30pm-4:00pm The Value of New Developments for the Da Vinci Marketing Plan – Monika Hagen, MD
4:00pm-5:00pm Investment Business Plan for a Robotic Surgery Program – Vassilios Apostolopoulos, CEO of Athens Medical Group
5:00pm-5:30pm Robotic Surgery Program in Athens Medical Center. How Far and How Soon – Konstantinos Konstantinidis, MD
5:30pm-6:00pm Establishment of a New Robotic Surgical Program at a University Center: The Romanian Experience – Irinel Popescu, MD
6:00pm-7:00pm Guidelines for Initiation of a Successful Robotic Surgery Program – Ryan Rhodes, Vice-President, Clinical Marketing, Intuitive Surgical, Inc

7:00pm-8:30pm Welcome Reception Terpsichore D/Erato

THURSDAY, MAY 12, 2011
8:00am Registration/Coffee & Tea Middle Lobby (Convention Level)

8:30am-11:20am PLENARY SESSION Terpsichore ABC

Moderators: Fabrizio Luca, MD & Dimitrios Linos, MD, FACS
8:30am-9:00am Welcome/Presidential Address – Jacques Hubert, MD
9:00am-9:30am Keynote Lecture: From Hippocrates To da Vinci – Konstantinos Konstantinidis, MD
Introduced by: Ivo Broeders, MD
Advances in Clinical Robotics: The Year 2010-2011 Part I
9:30am-9:50am Advances in Pediatric Surgery – John J. Meehan, MD, FACS
9:50am-10:10am Benign and Malignant Gynecologic Disorders – Grigor Gorchev, MD , PhD, DSc
10:10am-10:30am Advances in Rectal Cancer – Alessio Pigazzi, MD, PhD
10:30am-10:50am Bariatric Surgery – Eric B.Wilson, MD
10:50am-11:20am The Transaxillary Thyroidectomy – Woong Youn Chung

11:20am-11:40 am Coffee & Tea Break Terpsichore D

11:40am-1:20pm PLENARY SESSION Terpsichore ABC

Moderators: Evangelos Georgiou, MD, PhD & Ivo Broeders, MD
From Experiment to Clinic: What’s Coming?
11:40am-12:00pm The Raven Robotic Surgical System – Michael Stark & Emilio Ruiz Morales, Eur Ing
12:00pm-12:20pm Sofie: Concept of a Table Mounted Three Armed Robot – Maarten Steinbuch, MD
12:20pm-12:40pm Mimic: from Table Top to Console – Jacques Hubert, MD
12:40pm-1:00pm Telemanipulation of Flexible Instruments – Ivo Broeders, MD
1:00pm-1:20pm Questions & Discussion

1:20pm Lunch on own/Exhibits & Posters Opens

2:00pm-4:00pm CONCURRENT SESSIONS

SS01: General Surgery I Terpsichore ABC
Moderator: Nikolaos Nikiteas, MD & Richard Satava, MD
S001: ROBOTIC VERSUS ENDOSCOPIC THYROIDECTOMY FOR THYROID CANCERS: A MULTI-INSTITUTIONAL ANALYSIS OF EARLY SURGICAL
OUTCOMES Jandee Lee, MD, PhD, Jong Ho Yun, MD, Kee Hyun Nam, MD, Woong Youn Chung, MD, PhD, Yonsei University College of Medicine

8 6 TH ANNUAL MIRA CONGRESS May 11-13, 2011

 S002: INITIAL RESULTS OF ROBOTIC-ASSISTED THYROIDECTOMY THROUGH A GASLESS TRANSAXILLARY APPROACH Andreas
Kiriakopoulos, MD, Efthimios Poulios, MD, Dimitrios Linos, MD, 1st Surgical Clinic, Department of Surgery, Hygeia Hospital, Athens, Greece
S003: THE USEFULNESS OF ROBOTIC THYROIDECTOMY FOR THE MANAGEMENT OF BENIGN THYROID DISEASE George Giannopoulos, MD,
Jae Hyun Park, MD, Jong Ju Jeong, MD, Sang-Wook Kang, MD, Woong Youn Chung, MD, Department of Surgery, Yonsei University College of Medicine
S004: A SURGICAL COMPLETENESS OF ROBOTIC THYROIDECTOMY: A PROSPECTIVE COMPARISON OF THE OPEN CONVENTIONAL
THYROIDECTOMY VERSUS THE ROBOTIC THYROIDECTOMY 1Jae Hyun Park, 2Jong Ho Yoon, 3Chi Young Lim, 1Kyu Hyung Kim, 1Sohee Lee, 1Haeng
Rang Ryu, 1Sang-Wook Kang, 1Jong Ju Jeong, 1Kee-Hyun Nam, 1Woong Youn Chung, 1Cheong Soo Park, 1) Yonsei University College of Medicine, 2) Asan
Medical Center, University of Ulsan College of Medicine, 3) National Health Insurance Corporation Ilsan Hospital
S005: A COMPARATIVE STUDY OF ROBOTIC VERSUS CONVENTIONAL OPEN MODIFIED RADICAL NECK DISSECTION FOR THE PAPILLARY
THYROID CARCINOMA WITH LATERAL NECK NODE METASTASIS Sang-Wook Kang, MD, Kyu Hyung Kim, MD, Jae Hyun Park, MD, So Hee Lee,
MD, Woong Youn Chung, MD, Department of Surgery, Yonsei University College of Medicine
S006: ROBOTIC SURGERY OF SPLENIC CYSTS Catalin Vasilescu, Assoc. Prof., PhD, Stefan Tudor, Dana Elena Giza, Fundeni Institute of Digestive Disease
and Liver Transplantation, Bucharest, Romania
S007: ROBOTIC SINGLE PORT COLON RESECTIONS: INITIAL EXPERIENCE Rami Makhoul, MD, Grace Montenegro, MD, Vincent Obias, MD,
George Washington University
S008: 180 GENERAL SURGERIES UNDER DA VINCI S SYSTEM IN ONE INSTITUTE IN CHINA Ningxin Zhou, Junzhou Chen, Quanda Liu, Xiaodong Zhang,
Qiang Sun, Yu Xie, Qijun Xia, Zhizhong Zhang, Zhenyu Zhu, Institute of Hepatobiliary & Gastrointestinal Diseases, PLA Second Artillery General Hospital
S009: IS THERE ANY ROLE OF ROBOT-ASSISTED SURGERY OVER LAPAROSCOPIC SURGERY FOR GASTRIC CANCER? Young-Woo Kim, PhD,
Hong Man Yoon, MD, Jun Ho Lee, PhD, Keun Won Ryu, PhD, Bang-Ul Eom, MD, Il Ju Choi, PhD, Chan Gyoo Kim, PhD, Soo Jeong Cho, PhD, Jong Seok
Lee, MD, Myeong-Cherl Kook, PhD, Ji Young Rhee, Gastric Cancer Branch, Research Institute and Hospital, National Cancer Center, Korea
S010: ROBOTIC TRANSANAL ABDOMINAL ANORECTAL RESECTION ( TATA) WITH SPHINCTER PRESERVATION FOR CANCER IN THE
DISTAL RECTUM AFTER NEOADJUVANT THERAPY G. Spinoglio, MD, R. Quarati, MD, F. Priora, MD, LM Lenti, PhD, F. Ravazzoni, PhD, V.
Maglione, MD, Division of Oncologic General Surgery, ASO “SS Antonio e Biagio e Cesare Arrigo”, Alessandria, Italy
S011: PEDIATRIC ROBOTIC SURGERY: THE ULTIMATE DIVERSITY John J. Meehan, MD, Seattle Children’s Hospital, University of Washington
S012: ROBOT-ASSISTED TOTAL GASTRECTOMY FOR EARLY GASTRIC CANCER COMPARING WITH LAPAROSCOPY-ASSISTED TOTAL
GASTRECTOMY Young-Woo Kim, PhD, Hong Man Yoon, MD, Jun Ho Lee, PhD, Keun Won Ryu, PhD, Il Ju Choi, PhD, Chan Gyoo Kim, PhD, Soo
Geong Cho, PhD, Jong Seok Lee, PhD, Myeong-Cherl Kook, PhD, Ji Young Rhee, PhD, Young-iee Park, PhD, Gastric Cancer Branch, Research Institute and
Hospital, National Cancer Center,Korea

SS02: General Surgery II Thalia 3

Moderators: Theodore Diamandis & Irinel Popescu, MD
S013: 58 OPERATIONS ON BILIARY MALIGNANT TUMOR UNDER DA VINCI S SYSTEM Ningxin Zhou, Junzhou Chen, Quanda Liu, Xiaodong Zhang,
Tao Zhang, Institute of Hepatobiliary & Gastrointestinal Diseases, PLA Second Artillery General Hospital
S014: ROBOT-ASSISTED PYLORUS PRESERVING GASTRECTOMY FOR GASTRIC CANCER Dong-Seok Han, MD, Yun-Suhk Suh, MD, Seong-Ho
Kong, MD, Hyuk-Joon Lee, MD PhD, Han-Kwang Yang, MD PhD, Department of Surgery1, Cancer Research Institute2 Seoul National University College of
Medicine, Seoul, Korea
S015: COMPARISON OF PERIOPERATIVE OUTCOMEAS BETWEEN CONVENTIONAL TOTAL LAPAROSCOPIC LIVER RESECTION AND
ROBOT-ASSISTED LAPAROSCOPIC LIVER RESECTION Chung Ngai Tang, MBBS FRCS, Eric C.H. Lai, MBChB MRCSEd FRACS, George P.C. Yang,
MBBS MRCSEd FRACS, Oliver C.Y. Chan, MBChB MRCSEd FRCS, Michael K.W. Li, MBBS FRCS, Department of Surgery, Pamela Youde Nethersole
Eastern Hospital, Chai Wan, Hong Kong SAR, China
S016: THE IMPACT OF BODY HABITUS ON SURGICAL OUTCOMES OF TRANSAXILLARY SINGLE-INCISION ROBOTIC THYROIDECTOMY IN
PAPILLARY THYROID MICROCARCINOMA (PTMC) PATIENTS Sohee Lee, Haeng Rang Ryu, Jae Hyun Park, Kyu Hyung Kim, Sang-Wook Kang, Jong
Ju Jeong, Kee-Hyun Nam, Woong Youn Chung, Cheong Soo Park, Department of Surgery, Yonsei University Health System
S017: EXPERIENCE IN 17 CASES OF ROBOTIC LIVER RESECTION Ningxin Zhou, Quanda Liu, Junzhou Chen, Institute of Hepatobiliary &
Gastrointestinal Diseases, PLA Second Artillery General Hospital
S018: ROBOTIC SLEEVE GASTRECTOMY. A BETTER APPROACH FOR THE UPPER GASTRIC DISSECTION Jose Manuel Fort, PhD, Ramon
Vilallonga, PhD, Manel Armengol, PhD, Universitary Hospital Vall d’Hebron, Barcelona
S019: ROBOTIC RECTAL CANCER SURGERY VERSUS LAPAROSCOPIC RECTAL CANCER SURGERY IN A SINGLE CENTER EXPERIENCE:
SHORT TERM OUTCOMES ANALYSIS Irinel Popescu, MD, PhD, FACS, Victor Tomulescu, MD, PhD, Catalin Vasilescu, MD, PhD, Serban Vasile, MD,
Olivia Sgarbura, MD PhD, Vlad Herlea, MD PhD, Fundeni Institute of Digestive Diseases and Liver Transplantation
S020: ROBOTIC GASTRIC BYPASS: REDUCING ANASTOMOTIC COMPLICATIONS Francois Pugin, MD, Pascal Bucher, MD, Monika Hagen, MD,
Nicolas Buchs, MD, Gilles Chassot, MD, Philippe Morel, MD, University Hospitals Geneva
S021: COMPARATIVE EVALUATION BETWEEN THE ROBOTIC AND OPEN ULTRA-LOW ANTERIOR RESECTION IN PATIENTS WITH LOWER
RECTAL CANCER Jin C. Kim, MD, Kyung H. Kim, MD, Sung S. Yang, MD, Jae Y. Kwack, MD, Tae Y. Chang, MD, Seok B. Lim, MD, Department of
Surgery, University of Ulsan College of Medicine and Asan Medical Center, Seoul 138-736, Korea
S022: ROBOTIC COLORECTAL PROCEDURES: OUR EXPERIENCE G. Spinoglio, MD, R. Quarati, MD, F. Priora, MD, LM Lenti, PHD, F. Ravazzoni,
PHD, V. Maglione, MD, Division of Oncologic General Surgery, ASO “SS Antonio e Biagio e Cesare Arrigo”, Alessandria , Italy.
S023: TELELAP ALF-X- THE FUTURE OF ABDOMINAL SURGERY (BACK TO THE FINGERTIPS) Michael Stark, MD, Emilio Morales, SOFAR SpA,
The New European Surgical Academy; Telelap ALF-X Surgical Robotics Department
S055: ROBOT AND LAPAROSCOPIC ASSISTED GASTRECTOMY: A COMPARISON OF SURGICAL OUTCOMES Byunghee Kang MD, Junyoung Kim
MD, Sanguk Han MD, Department of Surgery, Ajou University,School of Medicine, Korea

SS03: Urology (2:00pm-3:00pm) Thalia 4

Moderators: Jacques Hubert, MD & Vassilis Poulakis, MD, PhD, FEBU
S024: SURGICAL, ONCOLOGIC AND FUNCTIONAL OUTCOMES IN PATIENTS WITH A GLEASON SCORE 8 OR HIGHER UNDERGOING
ROBOTIC-ASSISTED RADICAL PROSTATECTOMY Apostolos P. Labanaris, MD, PhD, Vahudin Zugor, MD, PhD, Jorn H. Witt, MD, PhD, Department
of Urology and Pediatric Urology - Prostate Center Northwest, St. Antonius Medical Center, Gronau, Germany
S025: ROBOTIC-ASSISTED LAPAROSCOPIC LIVING DONOR NEPHRECTOMIES: EXPERIENCE IN 100 CASES J. Hubert, MD, M. Ladriere, MD
PhD, C. Waked, MD, PhD, G. Chopin, MD, P. Eschwege, MD, PhD, P. Eschwege, MD, PhD, L. Frimat, MD, PhD, M. Kessler, MD, Dept. of Urology and
Nephrology, CHU Nancy-Brabois, allée du Morvan, 54511 Vandœuvre les Nancy, France
www.mirasurgery.org 9
SCIENTIFIC PROGRAM
S026: ROBOT-ASSISTED PARTIAL NEPHRECTOMY (RAPN). EXPERIENCE IN 60 CASES E. Barbier, PE Theveniaud, N. Hubert, MD, P. Eschwege,
MD, PhD, J. Hubert, MD, PhD, Urology Dept, CHU de Nancy-Brabois. Allée du Morvan, 54511 Vandoeuvre-Les-Nancy, France
S027: ROBOTIC ASSISTED LAPAROSCOPIC TRANSPERITONEAL PYELOPLASTY: 10 YEARS EXPERIENCE, 100 CASES J. Hubert, MD, M. Chammas,
MD, C. Egrot, MD, N. Hubert, MD, P. Eschwege, MD, PhD, J. Hubert, Department of Urology, CHU Nancy-Brabois 54511 Vandœuvre les Nancy, France
S028: ROBOTIC PROSTATECTOMY. FEASIBLE AND SAFE IN PATIENTS WITH PREVIOUS ABDOMINAL SURGERY Apostolos P. Labanaris, MD,
PhD, Vahudin Zugor, MD, PhD, Jorn H. Witt, MD, PhD, Department of Urology and Pediatric Urology, Prostate Center Northwest, St. Antonius Medical
Center, Gronau, Germany
S029: KEY AREAS IN THE LEARNING CURVE FOR ROBOTIC UROLOGICAL SURGERY: A SPANISH MULTICENTRE SURVEY Jesus Moreno Sierra,
MD, PhD, Elena Ortiz Oshiro, MD, PhD, Isabel Galante Romo, PhD, Jose Luis Senovilla, PhD, Ivan Mansilla Garcia, Maria Escudero Romo, Angel Silmi
Moyano, MD, PhD, Hospital Clinico San Carlos - Universidad Complutense de Madrid

SS04: Cardio-Thoracic (3:00pm-4:00pm) Thalia 4

Moderators: Aristotelis Panos, MD, PhD, FECTS & V. Tomulescu
S030: ROBOTIC MITRAL VALVE REPLACEMENT Changqing Gao, MD, PLA General Hospital
S031: MID-TERM FOLLOW UP AFTER ROBOTICALLY ASSISTED TOTALLY ENDOSCOPIC REPAIR OF INTRAATRIAL COMMUNICATIONS
Nikolaos Bonaros, Stepan Cerny, Felix Weidinger, Christoph Steger, Martin Michel, Silvana Mueller, Thomas Bartel, Johannes Bonatti, Thomas Schachner,
Department iof Cardiac Surgery, Innsbruck Medical University
S032: ROBOTIC TOTALLY ENDOSCOPIC CORONARY ARTERY BYPASS GRAFTING ON THE ARRESTED HEART – TWO CENTERS’
EXPERIENCE WITH 305 CASES Eric J. Lehr, MD, PhD, Thomas Schachner, MD, Nikolaos Bonaros, MD, Dominik Wiedemann, MD, Felix Weidinger,
MD, David Zimrin, MD, Bartley Griffith, MD, Johannes Bonatti, MD, University of Maryland School of Medicine, Medizinische Universität Innsbruck
S033: SEQUENTIAL CORONARY BYPASS GRAFTS FOR ROBOTICALLY ASSISTED TOTALLY ENDOSCOPIC SURGICAL REVASCULARIZATION
OF MULTIVESSEL CORONARY ARTERY DISEASE Eric J. Lehr, MD, PhD, Thomas Schachner, MD, Nikolaos Bonaros, MD, Dominik Wiedemann, MD,
Felix Weidinger, MD, Andreas R de Biasi, BS, Alina Grigore, MD, Mark Vesely, MD, Griffith Bartley, MD, Johannes Bonatti, MD, University of Maryland
School of Medicine, Medizinische Universität Innsbruck
S034: ROBOTIC THORACOSCOPIC FIRST RIB RESECTION - PRESENTATION OF A SERIES OF PATIENTS Farid Gharagozloo, Marc Margolis, MD, Eric
Strother, CSA, Barbara Tempesta, CRNP, Washington Institute Of Thoracic And Cardiovascular Surgery; The George Washington University Medical Center
S035: ROBOTIC CARDIAC SURGERY IN GREECE Aristotelis Panos, PhD, FECTS, FMH, Fotis Milas, MD, Sylvio Vlad, MD, 3rd Clinic for Cardiac
Surgery, Hygeia Hospital, Athens, Greece. La Tour Hospital, Geneva, Switzerland

4:00pm-4:30pm Coffee & Tea Break Terpsichore D

4:30pm-5:30pm CONCURRENT VIDEO SESSIONS

SS05: General Surgery Terpsichore ABC
Moderators: Fabrizio Luca, MD & Harilaos Pappis, MD, PhD, FACS
V001: ROBOTIC-ASSISTED RESECTION OF ESOPHAGEAL LEIOMYOMA Koji Park, MD, Syed Razi, MD, Jordan Sasson, MD, Cliff P. Connery, MD,
George J. Todd, MD, Scott J. Belsley, MD, Faiz Y. Bhora, MD, St. Luke’s-Roosevelt Hospital Center
V002: ROBOTIC SINGLE PORT RIGHT HEMICOLECTOMY IN AN OBESE PATIENT Vincent Obias, MD, Rami Makhoul, MD, Sam Damle, MD, Grace
Montenegro, MD, George Washington University
V003: ROBOT-ASSISTED THORACOSCOPIC ESOPHAGECTOMY AND LYMPHADENECTOMY Roy Verhage, MD, PC van der Sluis, MD, R van
Hillegersberg, MD, PhD, University Medical Center Utrecht, the Netherlands
V004: ROBOTICS MAY SAVE THE DAY WITH GANGRENOUS CHOLECYSTITIS: A NOT SO USELESS OPERATION AFTER ALL Konstantinos M.
Konstantinidis, MD, PhD, FACS, Savas C. Hiridis, Periklis S. Chrysocheris, Michael K. Georgiou, MD, Athens Medical Center
V005: ROBOTIC DISTAL PANCREATECTOMY: OUR TECHNIQUE Konstantinos M. Konstantinidis, MD, PhD, FACS, Savas C. Hiridis, MD, MSc,
Michael K. Georgiou, Perikles S. Chrysocheris, MD, aFACS, Athens Medical Center
V006 KIDS SAY THE DARNDEST THINGS...AND WHAT THEY EAT IS PRETTY WEIRD TOO John J. Meehan, Seattle Children’s Hospital, University
of Washington

SS06: Gynecology Thalia 3

Moderators: Vasiliki Chatzirafail, MD & Grigor Gorchev, MD, PhD, DSc
V007: ROBOTIC TRACHELECTOMY Vasilis Kapetanakis, MD, Paul M. Magtibay, MD, Mayo Clinic, AZ
V008: A PECULIAR VASCULAR INJURY IN ROBOTIC HYSTERECTOMY Rhoda Raji, MD, Karim ElSahwi, MD, Masoud Azodi, MD, Yale-New Haven Hospital
V009: ROBOTIC HYSTERECTOMY FOR STAGE IV ENDOMETRIOSIS Dan-Arin Silasi, MD, Taryn Gallo, MD, Yale New Haven Health / Bridgeport Hospital
V010: ROBOTIC RADICAL HYSTERECTOMY FOR VAGINAL SARCOMA Eugene P. Toy, MD, Julietta Fiscella, MD, University of Rochester
V011: ROBOTIC HYSTERECTOMY: APPROACH TO THE BULKY FIBROID UTERUS Mona Orady, MD, Division of Minimally Invasive Gynecology and
Robotic Surgery, Department of Obstetrics, Gynecology, and Women’s Health, Henry Ford Health System, Detroit, MI, USA
V012: ROBOTIC APPENDECTOMY DURING GYNECOLOGIC SURGERY: 3 DIFFERENT TECHNIQUES Taryn N. Gallo, MD, Dan-Arin Silasi, MD,
Masoud Azodi, MD, Yale New Haven Health / Bridgeport Hospital

SS07: Urology/Thoracic/Pediatric/Miscellaneous Thalia 4

Moderators: Nikolaos P. Pardalidis, MD, John Meehan, MD
V013: ROBOTIC RADICAL PROSTATECTOMY IN GREECE:5-YEAR EXPERIENCE Nick Pardalidis, Nick Andriopoulos, Aggelos Karamanis, Niki
Giannakou, Eleni Kosmaoglou, Athens Medical Centre, Marousi, Greece
V014: ROBOTIC-ASSISTED INSERTION OF AN ARTIFICIAL URINARY SPHINCTER AFTER PELVIC TRAUMA AND URETHRAL DISRUPTION
Jonathan J. Melquist, MD, Ruth Ann Miles, MD, Zelik Frischer, MD, Rahuldev Bhalla, MD, Stony Brook University Medical Center
V015: SEQUENTIAL PHOTOSELECTIVE VAPORIZATION OF THE PROSTATE AND ROBOT-ASSISTED LAPAROSCOPIC BLADDER
DIVERTICULECTOMY Nick Pardalidis, Nick Andriopoulos, Aggelos Karamanis, Eleni Kosmaoglou, Athens Medical Centre
V016: ROBOTIC ASSISTED ANTERIOR EXENTERATION FOR URETHRAL CANCER Rhoda Raji, MD, Karim Elsahwi, MD, Masoud Azodi,
Department of Obstetrics, Gynecology and Reproductive Sciences, Yale-New Haven Hospital, New Haven, CT, 06520

10 6 TH ANNUAL MIRA CONGRESS May 11-13, 2011

 V017: ROBOT-ASSISTED LAPAROSCOPIC RADICAL CYSTOPROSTATECTOMY: TOTALLY INTRACORPOREAL STUDER NEOBLADDER Nick
Pardalidis, Nick Andriopoulos, Niki Giannakou, Evagelia Karagianni, Eleni Kosmaoglou, Athens Medical Center, Maroussi, Athens, Greece
V018: ROBOTIC THYMECTOMY IN A CHILD WITH MYESTHENIA GRAVIS Jacob Stephenson, MD, John J. Meehan, MD, FACS, Daniel Ledbetter,
MD, Seattle Children’s Hospital
V019: ROBOTIC MICROSURGICAL NERVE GRAFTING FOR SYMPATHECTOMY REVERSAL: TECHNIQUE AND FEASIBILITY FOR FIRST
HUMAN CASE M Jawad Latif, MD, Koji Park, MD, Syed S. Razi, MD, Faiz Bhora, MD, George Todd, MD, Noel Perin, MD, Cliff Connery, MD, Scott J.
Belsley, MD, St. Luke’s Roosevelt Hospital Center, Columbia University
V020: ROBOTIC-ASSISTED THORACOSCOPIC REPAIR OF A DIAPHRAGMATIC HERNIA WITH LIVER HERNIATION AND ENDOMETRIOSIS
CAUSING RECURRENT CATAMENIAL PNEUMOTHORAX Gary S. Schwartz, MD, Koji Park, MD, Syed Razi, MD, Scott J. Belsley, MD, Faiz Y Bhora,
MD, Cliff P Connery, MD, St. Luke’s-Roosevelt Hospital Center

5:30pm Keynote Lecture: Intuitive Surgical and the Future of Robotic Surgery Terpsichore ABC
Ryan Rhodes, Vice-President, Clinical Marketing, Intuitive Surgical, Inc.
Introduction by: Konstantinos Konstantinidis, MD
6:00pm Grand Opening Ceremony Bishop/Terpsichore ABC
Welcome message from governmental and academic authorities.
8:30pm Gala Dinner: Dreams Asteras Seaside
Come join your colleagues and friends for an evening of dinner and music at the lovely Dreams Nea Asteria Glyfadas. Located
at the beach, Dreams Nea Asteria Glyfadas offers a view of the endless blue Argosaronicos Gulf and will provide an enchanting
atmosphere for this year’s MIRA Gala Event. Attire: Casual, but bring a coat as we will be near the water and it could get chilly!
*Shuttles will depart at 8:00pm from the lobby of the Hilton Athens and be available at 10:00pm to bring attendees back to the Hilton.

FRIDAY, MAY 13, 2011

7:30am-8:00am Coffee & Tea Break
8:00am MIRA Business Meeting (All Members Welcome) Terpsichore ABC
8:30am-10:00am Robotics in Space
Moderators: Mehran Anvari, Chair of Minimally Invasive Surgery & Surgical Innovation,
McMaster University, Canada, & Richard Satava, MD
1. Scope of Robotics in Space Program – NASA/CSA Representative TBA
2. Design and capabilities of space Robotic Systems – John Lymer, Chief Engineer, Space Robotic Program, MDA
3. Transition from Space to Medical Robotics – Mehran Anvari, Chief Scientist, NASA NEEMO Missions 7 & 9
10:00am-10:15am Coffee & Tea Break Terpsichore D
10:15am-11:15am Single Incision Symposium Terpsichore ABC
Moderators: Giuseppe Spinoglio, MD & Konstantinos Konstantinidis, MD
10:15am-10:30am Introduction: Intuitive Engineer: Da Vinci Single Incision Concept – Ryan Rhodes, Vice President, Clinical Marketing, Intuitive Surgical, Inc.
10:30am-10:45am The Greek Experience – Konstantinos Konstantinidis, MD
10:45am-11:00am The Swiss Experience – Monika Hagen, MD
11:00am-11:15am The Italian Experience – Giuseppe Spinoglio, MD
11:15am-1:35pm Advances in Clinical Robotics: The Year 2010-2011 Part II Terpsichore ABC
Moderators: Ivo Broeders, MD & Piero Giulanotti, MD
11:15am-11:35am Liver and Pancreas – Piero Guilianotti, MD, FACS
11:35am-11:55am Cardiac Surgery – Johannes Bonatti, MD
11:55am-12:15pm Lung and Esophagus – Farid Gharagoozlo, MD
12:15pm-12:35pm Upper GI – Georges Lawsons, MD
12:35pm-12:55pm Robotic Surgery in Romania – Irinel Popescu, MD
12:55pm-1:25pm Improving Outcomes for 6 Million Patients: OR Ready/The Information You Need When and Where You
Need It - SLS Scholarly Search for Minimally Invasive Robotic Surgery – Paul Wetter, MD
1:25pm-1:35pm Q&A with Panelists
1:35 pm Lunch on own/Exhibits & Posters Opens
2:30pm-3:30pm CONCURRENT SESSIONS
SS08: Gynecology Terpsichore ABC
Moderators: Georgios E. Hilaris, MD, FACOG & John S Missanelli, DO
S036: SENTINEL LYMPH NODE MAPPING IN PATIENTS WITH ENDOMETRIAL CANCER UNDERGOING ROBOTICALLY ASSISTED OR
STANDARD LAPAROSCOPIC PROCEDURES Mario M. Leitao, MD, Fady Khoury-Collado, MD, Ginger J. Gardner, MD, Elizabeth Jewell, MD, Carol L.
Brown, Yukio Sonoda, MD, Douglas A. Levine, MD, Richard R. Barakat, MD, Nadeem R. Abu-Rustum, MD, Memorial Sloan-Kettering Cancer Center

www.mirasurgery.org 11
SCIENTIFIC PROGRAM
S037: A COMPARISON OF PERIOPERATIVE OUTCOMES BETWEEN ROBOTIC AND OPEN HYSTERECTOMY FOR VERY ENLARGED UTERI
Fiona Lindo, MD, Taryn Gallo, MD, Masoud Azodi, MD, Dan-Arin Silasi, MD, Yale New Haven Health / Bridgeport Hospital
S038: LEARNING CURVE FOR ROBOTIC HYSTERECTOMY: THE HENRY FORD EXPERIENCE Mona E. Orady, MD, Department of Obstetrics,
Gynecology, and Women’s Health, Henry Ford Health System, Detroit, Michigan.
S039: SAFETY AND EFFICACY OF ROBOTIC MYOMECTOMY Vasiliki Chatzirafail, MD, Michael Litos, MD, PhD, MRCOG, Theodoros Mitsis, MD,
Nikolaos Bardis, MD, Aristidis Bakas, MD, Eyroclinic,Athens, Greece
S040: LAPAROSCOPIC VS ROBOTIC FIBROID RESECTION: EXPERIENCE 2008-2010 Konstantinos P. Mirillas, MD, Konstantinos P. Mirillas, MD, Petros C.
Hiridis, MD, Dimitris Bisbikis, MD, Savas C. Hiridis, MD, MSc, Perikles S. Chrysocheris, MD, Konstantinos M Konstantinidis, MD, PhD, FACS, Athens Medical Center

SS09: Pediatric Surgery and TORS Thalia 3

Moderator: Se-Heon Kim, MD & Georges Lawson, MD
S041: USE OF ROBOT IN HIGH ANORECTAL MALFORMATION Abdulrahman Albassam, MD, Abdulmonem Gado, MD, Mohammed Mallick, MD,
Division of Pediatric Surgery, Department of Surgery, King Khalid University Hospital,
S042: FEASIBILITY AND ONCOLOGIC SAFETY OF TRANSORAL ROBOTIC HYPOPHARYNGECTOMY Se-Heon Kim, MD PhD, Young Min Park,
MD, Armando De Virgilio, MD, Yonsei University College of Medicine
S043: IS UKA MORE ACCURATE WITH ROBOTIC ASSISTANCE? Nicholas J. Dunbar, MS, Andrew D. Pearle, MD, Eduardo M. Suero, MD, Sharon
Horowitz, BS, Michael A. Conditt, PhD, Scott A. Banks, PhD, University of Florida, Hospital for Special Surgery, MAKO Surgical Corp

SS10: Novel Applications – Simulation, Research, & Miscellaneous Thalia 4

Moderators: Nikos Aspragathos & Mehran Anvari, MD
S044: VIRTUAL REALITY ROBOTIC SURGERY SIMULATOR: MIMIC® DV-TRAINER, A TOOL FOR CERTIFICATION? C. Perrenot, MD, M. Perez,
MD, N. Tran, MD, J. P. Jehl, J. Felblinger, MD, PhD, J. Hubert, MD, Urology Dept & IADI, CHU Nancy-Brabois. Allée du Morvan, 54511 Vandoeuvre-les-
Nancy, France
S045: DEVELOPMENT OF A SEMI-AUTOMATED ROBOT-ASSISTED FLEXIBLE ENDOSCOPE N. van der Stap, BS, R. Reilink, MS, I.A.M.J. Broeders,
Prof. Dr., S. Misra, Dr., S. Stramigioli, Prof. Dr. IR, MIRA, University of Twente; Meander Medical Center
S046: ADVANCED ROBOTIC MULTI-DISPLAY EDUCATIONAL SYSTEM (ARMES), AN INNOVATIVE REAL-TIME AUDIOVISUAL MENTOR
DURING COMPLEX ROBOTIC SURGERY Yanghee Woo, MD, Kazutaka Obama, MD PhD, Tae-il Son, MD, Hyung Il Kim, MD, Woo Jin Hyung, MD Phd,
Department of Surgery, Robot and Minimally Invasive Surgery Center at Yonsei University College of Medicine, Seoul, Korea
S047: DEVELOPMENT OF A USER INTERFACE FOR COLONOSCOPE CONTROL N. Kuperij, BSc, R. Reilink, MSc, IAMJ Broeders, Prof. Dr., MP
Schwartz, Dr., S. Stramigioli, Prof., University of Twente, Department of Technical Medicine, University of Twente, Enschede, The Netherlands
S048: ROBIN HEART - FROM VIRTUAL TO REAL SURGEON TOOLS Zbigniew Nawrat, MD, Pawel Kostka, PhD, Foudation of Cardiac Suregry Development

3:30pm-3:45pm Coffee & Tea Break Terpsichore D

3:45pm-5:00pm SS11: Plenary Best Abstract and Video Session Terpsichore ABC
Moderators: Ivo Broeders, MD & Mehran Anvari, MD
S049: ROBOT ASSISTED- VS. CONVENTIONAL LAPAROSCOPY: A STUDY OF THE IMPACT OF HYSTERECTOMY TYPE AND UTERINE SIZE
Gunjal Garg, Deslyn Hobson, Saima Ghazal, Ylbe Franco, Sonia Kim, S. Gene L. McNeeley, David C. Kmak, Awoniyi Awonuga, Susan L. Hendrix, Wayne
State University/ Detroit Medical center
S050: ROBOTIC-ASSISTED SALVAGE PROSTATECTOMY. SURGICAL, ONCOLOGIC AND FUNCTIONAL OUTCOMES Apostolos P. Labanaris, MD,
PhD, Vahudin Zugor, MD, PhD, Jorn H. Witt, MD, PhD, Department of Urology and Pediatric Urology – Prostate Center Northwest, St. Antonius Medical
Center, Gronau, Germany
S051: ONCOLOGICAL OUTCOMES OF ROBOTIC GASTRECTOMY FOR GASTRIC CANCER COMPARED TO LAPAROSCOPIC GASTRECTOMY
Kazutaka Obama, MD, Woo Jin Hyung, MD, PhD, Yanghee Woo, MD, Hyoung-Il Kim, Sung Hoon Noh, MD, PhD, Yonsei University College of Medicine
S052: MULTIDIMENSIONAL ANALYSES OF THE LEARNING CURVE OF ROBOTIC GASTRECTOMY FOR GASTRIC CANCER: A COMPARISON
WITH LAPAROSCOPIC GASTRECTOMY Hyoung-Il Kim, MD, Woo Jin Hyung, MD, Yanghee Woo, MD, Kazutaka Obama, MD, Sung Hoon Noh, MD,
Department of Surgery, Institute of Gastroenterology, and Cancer Metastasis Research Center Yonsei University College of Medicine, Seoul, Korea
S053: COMPARISON OF ROBOTICALLY ASSISTED AND STANDARD LAPAROSCOPIC PROCEDURES IN PATIENTS WITH ENDOMETRIAL
CANCER Mario M. Leitao, MD, Ginger J. Gardner, MD, Gabriel Briscoe, Kevin Santos, Elizabeth Jewell, MD, Nadeem R. Abu-Rustum, MD, Carol L.
Brown, MD, Dennis S. Chi, MD, Yukio Sonoda, MD, Richard R. Barakat, MD, Memorial Sloan-Kettering Cancer Center
V021: NOT A MATTER OF SIZE Vasiliki Chatzirafail, MD, Michael Litos, MD, PhD, MRCOG, Antigoni Issari, MD, Euroclinic, Athens, Greece
V022: ROBOTIC SURGERY FOR ENDOMETRIOSIS UTILIZING THE 5MM DAVINCI SYSTEM Taryn n Gallo, MD, Masoud Azodi, MD, Yale New
Haven Health / Bridgeport Hospital
S054: MULTICENTER STUDY OF ROBOTIC VERSUS ENDOSCOPIC THYROIDECTOMY FOR THYROID CANCERS: POSTOPERATIVE
OUTCOMES AND SURGEON ERGONOMIC CONSIDERATIONS Hee-Lee-Nah Suh, MD, Jandee Lee, MD, Sang Wook Kang, MD, Jeoung Ju Jung, MD,
Un Chung Choi, MD, Jong Ho Yun, MD, Woong Youn Chung, MD PhD, Ajou University School of Medicine1, Yonsei University College of Medicine2,Won-
Kwang University College of Medicine3, Ulsan University School of Medicine

5:00pm-5:15pm Coffee & Tea Break Terpsichore D

5:15pm-6:15pm The Robotic Olympic Contest Terpsichore ABC

Come Watch as the Top Eight Contestants battle it out for the Gold, Silver and Bronze Medals of the Robotic Olympics!
Moderators: Paul Alan Wetter, MD, Jacques Hubert, MD, Monika.Hagen, MD & Savas Hiridis, MD

6:15pm-7:00pm Robotics in Surgery: Where Are We Heading? – Richard Satava, MD, FACS Terpsichore ABC
Moderators: Ivo Broeders, MD & Konstantinos Konstantinidis, MD

7:00pm Closing Lectures Terpsichore ABC

Jacques Hubert, MD (Past President), Johannes Bonnati, MD (President) and Closing Remarks from Congress President
12 6 TH ANNUAL MIRA CONGRESS May 11-13, 2011
 Oral Abstracts
S001: ROBOTIC VERSUS ENDOSCOPIC THYROIDECTOMY FOR
THYROID CANCERS: A MULTI-INSTITUTIONAL ANALYSIS OF EARLY
SURGICAL OUTCOMES Jandee Lee, MD PhD, Jong Ho Yun, MD, Kee Hyun
Nam, MD, Woong Youn Chung, MD PhD Yonsei University College of Medicine
Objectives: Robotic thyroidectomy has several advantages over conventional
endoscopic thyroid surgery, including a three-dimensional surgical view, and
fine and free movement of the robotic arm in the surgical fields. However,
few studies have compared the robotic and pure endoscopic thyroidectomy
techniques in terms of postoperative outcomes. The aim of this multicenter
study was to confirm the merits of robotic thyroidectomy by comparing
endoscopic thyroidectomy in patients with thyroid carcinomas.
Materials & Methods: Between November 2001 and June 2010, a total of 2,612
patients with thyroid carcinomas underwent at three centers by four surgeons.
Of these patients, 1,769 patients underwent robotic thyroidectomy (robotic
group), and 843 patients a conventional endoscopic thyroidectomy (endoscopic
group). These two groups were retrospectively compared with respect to patient
characteristics, operative outcomes, complications, and pathologic results.
Results: The patient demographics were similar in both groups. A total of 856
(32.8%) total thyroidectomy and 1274 (67.2%) less-than total thyroidectomy
was carried out. Total thyroidectomy was performed more frequently in the
robotic group (p=0.004). The groups were comparable in tumor size, pathology,
multiplicity, and bilaterality. However, tumor stage in the robotic group was
more advanced than in the endoscopic group (p=0.002). Statistically significant
differences were noted in favor of robotic vs. endoscopic total thyroidectomy with
regard to operative times (p<0.001). The total number of retrieved central lymph
nodes was greater in the robotic group (p=0.012). The two groups showed no
significant differences in terms of intra-operative and postoperative complications.
Conclusion: Robotic thyroidectomy using a gasless transaxillary approach was a
feasible, safe procedure and provided good outcomes for differentiated thyroid
carcinoma patients. The present study also showed that robot technology
overcame some technical limitations associated with conventional endoscopic
procedures in terms of operation time, and lymph node retrieval.
S002: INITIAL RESULTS OF ROBOTIC -ASSISTED THYROIDECTOMY
THROUGH A GASLESS TRANSAXILLARY APPROACH Andreas
Kiriakopoulos, MD, Efthimios Poulios, MD, Dimitrios Linos, MD, 1st Surgical
Clinic, Department of Surgery, Hygeia Hospital, Athens, Greece
Aim: Patients that form keloid and need thyroidectomy do benefit from a
scarless neck approach via the axilla using the robotically assisted Chung
technique. We present our initial experience with this technique.
Patients & Methods: Eight patients (6 females and 2 males, mean age 38.8 yrs,
range: 30-56) having favorable body habitus (mean BMI 23.4, range: 18-30)
underwent robotic-assisted thyroidectomy through a gasless transaxillary
approach. All procedures were performed with the da Vinci S surgical robot
system using four robotic arms. Skin flap dissection, robot docking and
gasless robotic thyroidectomy comprise the operative steps involved. Patient’s
demographic data, operative time, complications, conversions, hospital stay
and cosmetic results are presented.
Results: Three lobectomies, two near-totals, two totals and one total
thyroidectomy with lateral lymph node dissection have been performed.
Mean diameter of the largest nodule in this series was 26.5 mm (range: 18-
60). Mean total operative time was 211 min (range: 165-250) consisting of
a mean 32 min (range: 20-40) flap dissection time, a mean 13 min (range:
10-20) docking time and a 166 min (range: 130-210) console time. We had
no conversions and a drain was left in place in all patients that was removed
2.8 days later. We had one temporary recurrent laryngeal nerve paralysis.
Two patients exhibited transient symptomatic hypocalcemia. Three patients
complained of hypoesthesia/disturbed sensation in the flap dissection area.
Mean hospital stay was 1.5 days (range: 1-3). Postoperative pain was minimal
and cosmetic results excellent.
Conclusions: Our preliminary results show that robotic-assisted thyroidectomy
through a transaxillary approach is safe and feasible. Robotic application is
associated with excellent view of the critical neck anatomy that allows precise
tissue handling and dissection. However, more studies are needed to define
its role in modern thyroid surgery and to convince both patients and medical
world about its actual advantages.
www.mirasurgery.org
S003: THE USEFULNESS OF ROBOTIC THYROIDECTOMY FOR THE
MANAGEMENT OF BENIGN THYROID DISEASE George Giannopoulos, MD,
Jae Hyun Park, MD, Jong Ju Jeong, MD, Sang-Wook Kang, MD, Woong Youn
Chung, MD Department of Surgery, Yonsei University College of Medicine
Introduction: Thyroid surgery for benign diseases involves mainly young women,
so cosmetic considerations have motivated the development of various “no
scar to the neck” operations. However, endoscopic techniques are often very
strenuous and perhaps, discouraging to adopt. Recent incorporation of robotic
technology in thyroid surgery, proposes a feasible, safe, extra-cervical approach,
alleviating most of the technical difficulties of endoscopy. In these terms,
endoscopic skills are possibly not a prerequisite. Herein we present our series of
benign thyroid diseases that underwent robot-assisted thyroidectomy, reviewing
the essential steps in proper patient selection.
Methods & Procedures: Thirty nine patients were operated in a single institution,
from November 2007 to October 2010. Indications for surgery were follicular/
Hürthle cell lesions smaller than 5 cm, nodules with indefinite/suspicious
fine-needle aspiration findings and Graves disease. All patients underwent
robot-assisted thyroidectomy using a gasless transaxillary approach, with
no conversion to open surgery. The characteristics of the patients and the
procedure were evaluated retrospectively.
Results: From a total of 39 patients, 34 were women and 5 men. Mean age was
38 ±10.9 years. The most common pathology was adenomatous hyperplasia
(21 lesions), followed by follicular adenoma (9 lesions). Hashimoto thyroiditis
was found in 4 cases and Graves’ disease was the indication in 5 cases. Mean
nodular lesion size was 1.8 ±1.1 cm; no lesion proved to be malignant in final
pathology. Twenty three patients underwent lobectomy, 11 subtotal and 5
total thyroidectomy. Mean operative time was 131.6 ±39.1 minutes and mean
postoperative hospital stay was 3 ±0.3 days. No intra-operative complications
occurred; postoperative complications were 1 transient hoarseness, 1 transient
hypocalcemia and 1 permanent unilateral RLN injury.
Conclusion: Robotic thyroidectomy with gasless transaxillary approach, although
recent and sophisticated, has already been applied in over 1000 thyroid cancer
patients in Korea and several teams in USA and Europe have demonstrated
their initial experience. Nevertheless, proper patient selection is imperative,
and patients with a follicular lesion concerned about a neck scar, seem to be the
best candidates. Small nodules suspicious for papillary cancer, are also a rational
choice, as the operation is not extended considerably. On the contrary, Graves’
disease should be reserved unless significant experience has gained.
S004: A SURGICAL COMPLETENESS OF ROBOTIC THYROIDECTOMY:
A PROSPECTIVE COMPARISON OF THE OPEN CONVENTIONAL
THYROIDECTOMY VERSUS THE ROBOTIC THYROIDECTOMY 1Jae
Hyun Park, 2Jong Ho Yoon, 3Chi Young Lim, 1Kyu Hyung Kim, 1Sohee Lee,
1
Haeng Rang Ryu, 1Sang-Wook Kang, 1Jong Ju Jeong, 1Kee-Hyun Nam, 1Woong
Youn Chung, 1Cheong Soo Park 1) Yonsei University College of Medicine, 2)
Asan Medical Center, University of Ulsan College of Medicine, 3) National
Health Insurance Corporation Ilsan Hospital
Background: With the application of da Vinci robotic system to thyroidectomy
fields, surgeons can perform a precise and accurate operation with improved
cosmesis. The aim of this study is to compare the surgical completeness of
two groups who underwent conventional open thyroidectomy versus robotic
thyroidectomy in papillary thyroid carcinoma patients.
Materials & Method: From March to November 2009, a total of 115 patients
with papillary thyroid carcinoma who underwent total thyroidectomy
and postoperative radioactive iodine(RAI) ablation therapy(30mCi) at
Yonsei University Health System were enrolled. Of these, 58 patients were
conventional open thyroidectomy group(OG) and 57 patients were robotic
thyroidectomy group(RG). These two groups were prospectively compared
with respect to clinicopathological characteristics, surgical outcomes and
surgical completeness.
Results: Mean age was significantly younger in RG. Mean tumor sizes were larger
in RG, but the incidence of capsular invasion, multifocality and bilaterality
showed no significant differences between two groups. Tumor and nodal status
showed no significant differences, but advanced stage is more frequent in OG.
In terms of surgical outcomes, there were no significant differences in numbers
of retrieved central nodes, lengths of postoperative hospital stay, and incidences
of postoperative complications. In terms of surgical completeness, stimulated
13
Oral Abstracts
serum thyroglobulin(Tg) level and relative 131 iodine uptake of operation
bed (thyroid uptake/whole body upatke and thyroid uptake/brain uptake)
was significantly higher in RG. However, serum Tg level which was measured
six months after RAI therapy under TSH suppression showed no significant
differences between two groups.
Conclusion: Robotic thyroidectomy showed a comparable surgical completeness
with conventional open procedure in papillary thyroid carcinoma patients who
were managed with RAI ablation therapy after total thyroidectomy.
S005: A COMPARATIVE STUDY OF ROBOTIC VERSUS CONVENTIONAL
OPEN MODIFIED RADICAL NECK DISSECTION FOR THE PAPILLARY
THYROID CARCINOMA WITH LATERAL NECK NODE METASTASIS
Sang-Wook Kang, MD, Kyu Hyung Kim, MD, Jae Hyun Park, MD, So Hee
Lee, MD, Woong Youn Chung, MD Department of Surgery, Yonsei University
College of Medicine
Purpose: Since the introduction of endoscopic technique to thyroid surgery, several
endoscopic lateral neck dissection trials have been conducted with the aim of
avoiding a long cervical scar, and the recent introduction of surgical robotic
systems has simplified and increased the precisions of endoscopic techniques.
The aim of this study was to evaluate and compare the early surgical outcomes
of robotic and conventional open modified radical neck dissection (MRND) for
papillary thyroid carcinoma (PTC) with lateral neck node metastasis (LNM).
Patients & Methods: From January 2009 to May 2010, 165 patients with PTC
underwent bilateral total thyroidectomy with ipsilateral MRND for PTC with
LNM. Of these patients, 56 underwent a robotic procedure using a gasless,
transaxillary approach (the robotic group; RG) and 109 a conventional open
procedure (the conventional open group; OG). These two groups were
retrospectively compared in terms of their clinicopathologic characteristics,
early surgical outcomes, and surgical completeness.
Results: The RG was younger than the OG(35.8±9.1 vs. 46.1±13.0, P<0.0001).
The operative time was longer in the RG than the OG(277.4±43.2 vs.
218.2±43.8min, P<0.0001). The number of retrieved lymph nodes were
similar between the RG and OG.(37.3±12.8 vs. 39.4±14.1, P=0.359). The RG
had smaller tumor size(1.14±0.59 vs. 1.49±0.80, P=0.004) and earlier stage
than the OG(stage I:IVa = 80.4%:19.6% vs. 46.3%:53.7%, P<0.0001). The
period of hospital stay after surgery was shorter in the RG than the OG(6.0±2.5
vs. 8±5.2, P=0.008). Compared with the OG, the complication-rate was not
different. There was no abnormal uptake on RAI scans in the two groups. The
mean level of serum Tg(TSH suppressed) were acceptable in the two groups.
The patients who had >1 ng/ml of serum Tg were 3 and 7 in the RG, and OG,
respectively(Tg level; 4.59±4.54 vs. 3.41±2.40).
Conclusions: Robotic MRND was found to be similar to conventional open
MRND in terms of early surgical outcomes and surgical completeness but to
offer an advantage of excellent cosmetic result. Based on our initial experiences,
robotic MRND should be viewed as an acceptable alternative method in low risk
PTC patients with lateral neck node metastasis.
S006: ROBOTIC SURGERY OF SPLENIC CYSTS Catalin Vasilescu, Assoc
Prof PhD, Stefan Tudor, Dana Elena Giza Fundeni Institute of Digestive Disease
and Liver Transplantation, Bucharest, Romania
Background: The authors reviewed their initial experience with robotic approach
for splenic cysts to identify the indications, success rate, and complications
associated with this procedure.
Materials & Methods: 60 patients aged 6 to 76 years (average 32.6 years)
underwent robotic splenectomy between February 2008 and September 2010
for different indications. Three patients with non-parasitic splenic cysts were
treated by robotic approach. The localization was in the upper pole in one
case, in the lower pole in one case and one case with multiple splenic cysts
and the procedures were one total splenectomy and two partial splenectomy.
Four patients with splenic hydatidosis were treated by robotic approach. The
localization was in the upper pole in one case and voluminous cysts in the hilar
region in the other three and the procedures were one hemisplenectomy and
three partial splenectomies with lower pole preservation.
Results: The mean operative time was 120 min (±37 min) with a console time
of 95 min (±28 min); the mean hospital stay was 5 days (±2 days). There
were no conversions to open or laparoscopic surgery. No morbidity and no
mortalities occurred.
14
Conclusion: Robotic splenectomy will probably not replace the laparoscopic
splenectomy for the most common indications like ITP, hemolytic anemia. It
may be a very useful surgical tool in difficult splenectomy and allows resection
of splenic cysts with a margin of healthy tissue without risk of bleeding or
recurrence. Robotic surgery of splenic cysts seems to offer safety and all benefits
of minimally invasive surgery, preserves the immune function of the spleen and
allows the surgeon to conserve as much of splenic parenchyma as possible.
S007: ROBOTIC SINGLE PORT COLON RESECTIONS: INITIAL
EXPERIENCE Rami Makhoul, MD, Grace Montenegro, MD, Vincent Obias,
MD, George Washington University
Introduction: The application of laparoscopic (Lap) single site surgery is increasing
in the field of minimally invasive surgery and recently has become more popular
in colon and rectal surgery. In addition to the possibility of decreasing post-
operative pain, it improves cosmesis and minimizes tissue trauma. However,
instrument conflict, poor ergonomics, and increased technical difficulty has
minimized its complete adaptation. We believe the Robotic (Rbt) system can
minimize these unique technical challenges. We would like to share our early
experience, the largest in the literature to date, with robotic single incision
colectomies with regards to safety and feasibility.
Methods: We analyzed 8 patients (pts) who underwent single incision Rbt right
hemicolectomy between March 2010 and October 2010 by a single surgeon at
our institution. The Rbt approach using the DaVinci-S Robot and SILS access
device was performed on these pts. A single 4cm incision around the umbilicus
was done, three robotic arms were used, and a medial to lateral approach with
extracorporeal resection and anastomosis was performed. At the beginning of
the case, the robotic arms are crossed and in the console the hand designations
are switched so that the right hand controls what looks to be the right
instrument (which is acutally the left crossed over) and vice versa. This improves
dexterity in the abdomen. Age, gender, body mass index (BMI), operative (Op)
time, estimated blood loss (EBL), morbidity, number of lymph nodes harvested
and length of hospital stay (LOS) were analyzed.
Results: There were no intra-operative complications. 3 of 8 pts who
underwent the robotic technique were converted to Lap due to air leaks
around the access device. There were no conversions to open. Mean Op
time was 203 min. Mean EBL was 125 ml and average LOS was 5.1 days.
Average number of lymph nodes harvested was 20.5. Morbidity included
prolonged ileus and aspiration pneumonia in one pt. Two other pts separately
experienced a wound infection and anastomotic bleeding, which resolved with
conservative management.
Conclusion: Robotic single incision right hemicolectomy can be successfully and
safely performed. The surgeon noted improved ergonomics and better bowel
manipulation compared to the Lap approach. Initial Op times were quite long,
but they are decreasing. Loss of pneumoperitoneum was the main cause of
conversion from Rbt surgery to Lap surgery, but upcoming advances in single
port robotic surgery should help reduce this problem. Further large scale studies
are needed to confirm these data.
S008: 180 GENERAL SURGERIES UNDER DA VINCI S SYSTEM IN ONE
INSTITUTE IN CHINA Ningxin Zhou, Junzhou Chen, Quanda Liu, Xiaodong
Zhang, Qiang Sun, Yu Xie, Qijun Xia, Zhizhong Zhang, Zhenyu Zhu Institute
of Hepatobiliary & Gastrointestinal Diseases, PLA Second Artillery General
Hospital
Objectives: To summarize the clinical experience in 180 general surgeries under
da Vinci S system.
Methods: From January 2009 to October 2010, 180 patients with hepato-
pancreatico-biliary (HPB) and gastrointestinal disease underwent robotic surgery
by using da Vinci S system. The clinical data of 180 patients were analyzed.
Results: 171 patients have undergone robotic surgery throughout. 9 patients
have converted to hand-assisted procedure and the conversion rate was 5.0%
(9/180). Among them, there were 63 surgeries in hepatic portal (including
36 in hilar cholangiocarcinoma, 10 in gallbladder carcinoma, 12 in complex
hepatolithiasis, and 5 in latrogenic bile duct injuries); 44 surgeries in pancreas
(including 16 in pancreaticoduodenectomy, 6 in resection of pancreatic body
and tail, 1 in medial pancreatectomy, 1 in pancreatic pseudocyst, and 20 in
palliative operations); 19 surgeries in liver; 12 surgeries in gastrointestinal;
and 42 in others (including lithotomy of common bile duct exploration,
6 TH ANNUAL MIRA CONGRESS May 11-13, 2011
 retroperitoneal lymph nodes dissection, and splenectomy and so on). There
were 12 cases with postoperative complications and the overall complication
rate was 6.7% (12/180). There were 2 died cases and the mortality rate was
1.1% (2/180). There were no device-related complications. Recovery was
accelerated and blood loss was less.
Conclusion: Almost all operations in hepato-pancreatico-biliary (HPB) surgery
could be performed successfully by employing da Vinci S system. Robotic surgery
will improve the development of minimally invasive surgery to a large extent.
S009: IS THERE ANY ROLE OF ROBOT-ASSISTED SURGERY OVER
LAPAROSCOPIC SURGERY FOR GASTRIC CANCER? Young-Woo Kim,
PhD, Hong Man Yoon, MD, Jun Ho Lee, PhD, Keun Won Ryu, PhD, Bang-
Ul Eom, MD, Il Ju Choi, PhD, Chan Gyoo Kim, PhD, Soo Jeong Cho, PhD,
Jong Seok Lee, MD, Myeong-Cherl Kook, PhD, Ji Young Rhee Gastric Cancer
Branch, Research Institute and Hospital, National Cancer Center, Korea
Purpose: A minimal invasive surgery has been developed, and proved to
increase short term quality of life in early gastric cancer. Robot-assisted distal
gastrectomy(RADG) has theoretical advantages over laparoscopy-assisted
distal gastrectomy(LADG) with regard to increased degrees of freedom of
instruments and enhanced dexterity through 3-dimensional view. The aim of
study was to see role of RADG for gastric cancer compared LADG.
Methods: We conducted single center-based case-control study. The study included
408 patients underwent LADG, and 115 patients underwent RADG in National
Cancer Center between Feb 2009 and Nov 2010. No patient in given period was
excluded in analysis. Clinicopathologic data, operation related data, postoperative
morbidity and pathologic data were analyzed by Student t-test and Chi-Square test.
Results: Age of patients was 58.72+11.7 in LADG and 53.6+12.1 in
RADG(p<0.001). Postoperative hospital days was 7.9+3.6 in LADG and
7.5+4.4 in RADG (p=0.391). BMI was 23.7+3.0 in LADG and 24.0+3.4 in
RADG (p=0.346). Operating time was 197.1+100.0 in LADG and 240.2+44.0
in RADG (p<0.001). Number of dissected lymph nodes was 33.6+12.1 in
LADG and 35.3+12.7 in RADG (p=0.189). In 431 patients who underwent
D2 lymph node dissection, number of dissected lymph nodes in N2 area was
13.0+6.3 in LADG and 14.9+7.3 in RADG. (p=0.01). Regarding postoperative
complications, there were 49 patients(12.0%) in LADG and 10 patients(8.7%) in
RADG (p=0.321).
Conclusions: RADG could have advantage over LADG in terms of more exact
dissection of lymph nodes at N2 area. Prospective controlled study is needed to
clarify this issue.
S010: ROBOTIC TRANSANAL ABDOMINAL ANORECTAL RESECTION
( TATA) WITH SPHINCTER PRESERVATION FOR CANCER IN THE
DISTAL RECTUM AFTER NEOADJUVANT THERAPY G Spinoglio, MD, R
Quarati, MD, F Priora, MD, LM Lenti, PhD, F Ravazzoni, PhD, V Maglione,
MD Division of Oncologic General Surgery, ASO “SS Antonio e Biagio e Cesare
Arrigo”, Alessandria, Italy
Aim: Surgical treatment of locally advanced distal rectal cancer remains the only
method for apotential cure. Robotic total mesorectal excision (RTME) has been
shown to be safe and effective. Great emphasis is placed not only on oncologic cure
but also on maintenance of quality of life with sphincter preservation We report our
initial experience with robotic radical transanal abdominal proctosigmoidectomy
with coloanal anastomosis (TATA) after neoadjuvant therapy.
Surgical Technique & Results: Our robotic activity began in December 2005 no
stopped in November 2007 and started again in March 2010 using the robotic
system Da Vinci® Si HD. 129 patients underwent colorectal robotic surgery. In
49cases we performed a RTME and in the last 3 patients, 2 males and 1 female, we
decided to proceed with sphincter-preserving surgery by TATA technique. All the
three patients were operated on 8 weeks after neoadjuvant therapy. The mean level
of the tumor to the anorectal ring was 3.3 cm ( range, 3-5 cm). The mean tumor
size was 5.3 cm (range: 3-7 cm). All tumors were mobile before surgery.
Conclusions: Robotic technology is especially suitable for dissection in narrow
spaces such as the pelvis, in which three-dimensional vision and increased
dexterity help in the performance of TME. Benefit of TATA approach is derived
from beginning the dissection transanally, that grants a maximal and precisely
assessed distal margin to the cancer.In our experience another advantage is the
greater freedom of movement of the rectum during TME that facilitates the
dissection in the narrow pelvic cavity.
www.mirasurgery.org
S011: PEDIATRIC ROBOTIC SURGERY: THE ULTIMATE DIVERSITY John
J Meehan, MD Seattle Children’s Hospital, University of Washington
Robotic surgery has huge potential in all forms of minimally invasive surgery.
Pediatric surgery is a unique field because it combines a wide variety of acquired
problems with numerous congenital malformations. Robotic surgery is a form
of minimally invasive surgery which has opened new fronitiers in the surgical
treatment of children. However, there are numerous limitations including
equiment size, patient size, and the economics of robotics in a children’s hospital
which has limited its potential growth. We present an 8 year summary and
review of our experience with over 300 pediatric general surgery robotic cases
and nearly 50 different types of procedures or diagnosis. The best applications
include mediastinal mass resections, complex hepatobiliary procedures,
GI procedures in both the upper abdomen and also in the pelvis, and most
genitourinary procedures. Fundoplications and cholecystectomies function
well as teaching cases for all levels of training. Procedures with less obvious
benefit include pulmonary lobectomies due to the availability of superior non-
robotic thermal sealing technologies as alternatives. Limitations include loss
of maneuverability in smaller patients below certain threshold sizes. These
limitations become more signifiicant in abdominal procedures for children
smaller than 3 kg and thoracic procedures for children less than 4 kg.
S012: ROBOT-ASSISTED TOTAL GASTRECTOMY FOR EARLY GASTRIC
CANCER COMPARING WITH LAPAROSCOPY-ASSISTED TOTAL
GASTRECTOMY Young-Woo Kim, PhD, Hong Man Yoon, MD, Jun Ho Lee,
PhD, Keun Won Ryu, PhD, Il Ju Choi, PhD, Chan Gyoo Kim, PhD, Soo Geong
Cho, PhD, Jong Seok Lee, PhD, Myeong-Cherl Kook, PhD, Ji Young Rhee,
PhD, Young-iee Park, PhD Gastric Cancer Branch, Research Institute and
Hospital, National Cancer Center,Korea
Purpose: In early gastric cancer, the quality of life has been important because
of long term survival. Minimal invasive surgery has been developed. However,
laparoscopy-assisted total gastrectomy(LATG) has been still more difficult
for surgeons than conventional open total gastrectomy. Robot-assisted total
gastrectomy(RATG) has theoretical advantages, such as increased degrees of
freedom of instruments and 3-dimensional view, over LATG . The aim of this
study was to compare RATG with LATG in early gastric cancer in terms of
surgical and oncologic outcomes
Methods: We conducted single center-based case-control study. The study
included 42 patients underwent LATG, and 29 patients underwent RATG at the
National Cancer Center, Korea between Feb 2009 and Nov 2010. No patient in
given period was excluded in analysis. Clinicopathologic data, operation related
data, postoperative morbidity and pathologic data were analyzed by Student
t-test and Chi-Square test.
Results: Age of patients was 57.1+12.2 in LATG and 54.0+12.3 in RATG
(p=0.293). Postoperative hospital days was 11.0+12.3 in LATG and 9.0 +3.6
in RATG (p=0.327). BMI was 23.6+3.1 in LATG and 23.1+2.7 in RATG
(p=0.485). Operating time was 211.7+58.5 in LATG and 314.6+37.0 in RATG
(p<0.001). Number of dissected lymph nodes was 41.2+14.0 in LATG and
42.8+11.5 in RATG(p=0.620). In 65 patients who underwent D2 lymph node
dissection, number of dissected lymph nodes in N2 area was 12.1+5.5 in LATG
and 12.8+4.8 in RATG. (p=0.564). Regarding postoperative complications,
there were 7(16.7%) in LATG and 5 (17.2%) in RATG (p=0.949).
Conclusion: Despite of early experiences, RATG was comparable to LATG
regarding to surgical and oncologic outcomes. Prospective controlled study is
needed to clarify this issue.
S013: 58 OPERATIONS ON BILIARY MALIGNANT TUMOR UNDER DA
VINCI S SYSTEM Ningxin Zhou, Junzhou Chen, Quanda Liu, Xiaodong Zhang,
Tao Zhang Institute of Hepatobiliary & Gastrointestinal Diseases, PLA Second
Artillery General Hospital
Objectives: To summarize the clinical experience in 58 operations on biliary
malignant tumor under da Vinci S system.
Methods: From January 2009 to October 2010, 58 patients (36 males, 22
females, aged from 48-85, with the average age of 68) with biliary tract
malignancy disease underwent robotic surgery by using da Vinci S system. The
clinical data of 58 patients were analyzed.
Results: 3 cases of intrahepatic bile duct cystadenocarcinoma received operations
of hepatectomy; 36 cases of hilar cholangiocarcinoma (62.1%, 36/58),
15
Oral Abstracts
including 3 anatomical left hepatectomies, 3 operations of extrahepatic bile
duct resection and gallbladder-bridge biliary reconstruction, 14 operations of
extrahepatic bile duct resection and biliary-enteric Roux-en-Y anastomosis,
1 tumor resection and reconstruction of hilar bile duct, 5 cases of palliative
bilary external drainage, and 10 cases of Y-type bilary internal drainage with T
tube; 10 cases of gallbladder carcinoma (including 2 operations of gallbladder
anf extrahepatic bile duct resection and biliary-enteric Roux-en-Y anastomosis,
3 cholecystectomies, 1 operation of cholecystectomy and bilary external
drainage, 4 operations of cholecystectomy, and Y-type bilary internal drainage
with T tube); 1 operation of middle common bile duct cancer (1.7%, 1/58),
with radical resection of extrahepatic bile duct biliary-enteric Roux-en-Y
anastomosis); 8 operations of lower common bile duct cancer (13.8%, 8/58)
, including 7 cases of pancreaticoduodenectomy and 1 case of biliary-enteric
Roux-en-Y anastomosis. 2 patients converted to hand-assistant procedure
and the convcersion was rate 3.4% (2/58). The complication rate was 13.8%
(8/58), including 3 postoperative bile leakage, 1 bleeding, 2 cases of pancreatic
anastomotic leakage, 1 pulmonary infection and 1 renal failure. Mortality rate
was 3.4% (2/58) with 1 patient dead from serious lung infection and the other
dead from postoperative renal failure.
Conclusion: Various types of operation about biliary malignant tumor can be
performed robotically. Robotic techniques are particularly valuable in very
challenging hilar biliary surgeries such as bile duct exploration, reconstruction
and anastomosis. Compared to laparoscope, da Vinci S System has broken the
limit in hepatobiliary surgeries in traditional open surgeries, especially for
patients with old age, jaundice and with advance disease, because they could
choose redical or palliative surgeries during the process.
S014: ROBOT-ASSISTED PYLORUS PRESERVING GASTRECTOMY FOR
GASTRIC CANCER Dong-Seok Han, MD, Yun-Suhk Suh, MD, Seong-Ho
Kong, MD, Hyuk-Joon Lee, MD PhD, Han-Kwang Yang, MD PhD Department
of Surgery1, Cancer Research Institute2 Seoul National University College of
Medicine, Seoul, Korea
Purpose: Laparoscopy-assisted pylorus preserving gastrectomy (LAPPG) is one
therapeutic option for early gastric cancer with preservation of gastric function.
The aim of this study is to evaluate the feasibility of robot-assisted pylorus
preserving gastrectomy (RAPPG) for early gastric cancer.
Patients & Methods: Between June 2008 and October 2010, 11 consecutive
patients who underwent RAPPG were analyzed. Indication for surgery was
preoperately diagnosed as cT2 or less and cN0 (AJCC/UICC 7th). After
informed consent, surgery was performed using da Vinci surgical system.
Results: All RAPPG cases were performed successfully without open or
laparoscopic conversion. The mean operation time and console time were
257 and 135 minutes. There were 2 (18.2%) morbidiy cases of intra-luminal
bleeding and wound complication. Gastric stasis is not observed in this study.
Estimated blood loss was 46.1 ± 33.4 ml (Mean ± SD). Sips of water and semi-
fluid diet were started on postoperative day 3.3 and 4.3. Mean postoperative
hospital stay was 7.7 days. All 11 patients were T1N0 (AJCC/UICC 7th) lesion
in final pathology report. The mean number of retrieved all lymph nodes and
LN stations 6 were 35.0 and 4.6, respectively.
Conclusion: RAPPG for early gastric cancer is a feasible technique in terms of
morbidity and lymph node dissection. But advantage of RAPPG over LAPPG is
not analyzed in this study because of the number of cases is limited. Our result
prompts a prospective clinical trial for the role of RAPPG.
S015: COMPARISON OF PERIOPERATIVE OUTCOMEAS BETWEEN
CONVENTIONAL TOTAL LAPAROSCOPIC LIVER RESECTION AND
ROBOT-ASSISTED LAPAROSCOPIC LIVER RESECTION Chung Ngai Tang,
MBBS FRCS, Eric C.H. Lai, MBChB MRCSEd FRACS, George P.C. Yang,
MBBS MRCSEd FRACS, Oliver C.Y. Chan, MBChB MRCSEd FRCS, Michael
K.W. Li, MBBS FRCS Department of Surgery, Pamela Youde Nethersole
Eastern Hospital, Chai Wan, Hong Kong SAR, China
Introduction: To compare the short term outcome between conventional total
laparoscopic liver resection and robot-assisted laparoscopic liver resection.
Methods & Procedures: A non-randomized comparative study was conducted on
49 consecutive patients, who underwent conventional total laparoscopic liver
resection (n=17) and robot-assisted laparoscopic liver resection (n=32) between
October 1998 and January 2011.
16
Results: Operation for malignant pathology was 70.6% and 78.1% for conventional
total laparoscopic group and robot-assisted laparoscopic group, respectively. The
rate of anatomical resection was 52.9%, and 81.3%, respectively. Two patients
(11.8%) in total laparoscopic group needed open conversion, and one patient
(3.1%) in robotic group needed to convert to hand-assisted approach. There was
no significant difference in mean operating time (88.6 vs. 209.5 minutes), median
blood loss (65 vs. 100 ml), complication rate (23.5 vs. 9.3%), procedure related
mortality rate (0 vs. 0%) and median hospital stay (11 vs. 5 days) between the 2
groups. There was no significant difference in R0 surgical margin rate (100% vs.
92.6%) for patients with malignant disease also.
Conclusion: Robot-assisted laparoscopic liver resection was feasible, and safe.
Robot-assisted approach tended to have a lower complication rate and shorter
hospital stay than conventional total laparoscopic approach.
S016: THE IMPACT OF BODY HABITUS ON SURGICAL OUTCOMES OF
TRANSAXILLARY SINGLE-INCISION ROBOTIC THYROIDECTOMY IN
PAPILLARY THYROID MICROCARCINOMA (PTMC) PATIENTS Sohee
Lee, Haeng Rang Ryu, Jae Hyun Park, Kyu Hyung Kim, Sang-Wook Kang, Jong
Ju Jeong, Kee-Hyun Nam, Woong Youn Chung, Cheong Soo Park Department
of Surgery, Yonsei University Health System
Background: Robotic applications have achieved safe and meticulous
thyroidectomy with notable cosmetic and functional benefits. The aim of this
retrospective study was to document the influence of body habitus on the
robotic thyroidectomy in papillary thyroid microcarcinoma (PTMC) patients.
Methods: From July 2009 to February 2010, 352 patients underwent the robotic
thyroidectomy using a gasless, transaxillary single-incision approach in the
Department of Surgery at the Yonsei University Health System, Seoul. Body
habitus which influenced on robotic thyroidectomy were described by body mass
index (BMI), neck length and shoulder width. Correlation between measures of
body habitus and surgical outcomes with respect to operation time, number of
retrieved central nodes, bleeding counts and postoperative complications were
retrospectively analyzed.
Results: Total 217 patients underwent a less than total thyroidectomy and 135
patients underwent a total thyroidectomy. In less than total thyroidectomy
cases, 177 patients were normal weight (BMI<25, NW), 35 patients were
overweight (25≤BMI<30, OW), and 5 patients were obese(30≤BMI, OB). In
total thyroidectomy cases, 105 patients were NW, 24 patients were OW, and
6 patients were OB. In terms of less than total thyroidectomy, operation time,
bleeding counts showed no significant differences between three BMI groups.
The neck length showed positive correlation with the console time in less than
total thyroidectomy. In terms of total thyroidectomy, total operation time
and working space time took longer in OB. However, the number of retrieved
central nodes and postoperative suppressed Tg level showed no significant
differences. The shoulder width showed positive correlation with the total
operation time, working space time, console time and the number of retrieved
central nodes. The postoperative complication showed no significant differences
between three BMI groups and it showed no significant correlation with neck
length or shoulder width.
Conclusion: Body habitus makes impact on the robotic operation time. However,
robotic thyroidectomy with sufficient working space can be performed safely
with similar surgical stage and without increasing intraoperative bleeding or
postoperative complication even in obese patients.
S017: EXPERIENCE IN 17 CASES OF ROBOTIC LIVER RESECTION
Ningxin Zhou, Quanda Liu, Junzhou Chen Institute of Hepatobiliary &
Gastrointestinal Diseases, PLA Second Artillery General Hospital
Objectives: To summarize the experience of robotic hepatectomy using the da
Vinci Surgical System.
Methods: The clinical data of 17 patients undergoing robotic hepatectomy from
January 2009 to July 2010 were reviewed.
Results: Seventeen patients undergoing robotic hepatectomy were 55±16
years (range 27-84 years), and with 8 male patients. The indication of robotic
hepatectomy were hepatocellular carcinoma (3), cholangiocarcinoma (3,
Bismuth IIIb type Klatskin tumor 1, and intrahepatic cystadenocarcinoma 2),
metastatic liver tumors (3), benign liver tumor (4, hepatic hemangioma 3, and
biliary cystadenoma 1), and left hepatolithiasis (4). Four cases with primary
benign liver tumors included liver hemangioma (3) and biliary cystadenoma
6 TH ANNUAL MIRA CONGRESS May 11-13, 2011
 (1); 12 cases with primary malignant liver tumors included hepatocellular
carcinoma (HCC) (9), and biliary carcinoma (3). The liver metastases were
from gallbladder cancer (4 cases), periampullar cancer (3), gastric cancer (1) and
rectal cancer (1). The robot-assisted surgical procedures consisted of anatomical
left hemihepatectomy (2), left lateral lobectomy (5), partial or wedged resection
(7), and s5a segementectmoy (1), together with other simultaneous robotic
procedures managing the primary diseases or comorbidities in 12 cases. The
average operative time for hepatectomy was 280min, and average intraoperative
blood loss was 150ml. Intraoperative massive bleeding occurred in 3 patients:
2 patients with giant hemangioma resulting in open conversion (11.8%).
Pringle’s inflow occlusion was used for 4 patients undergoing hepatectomy,
and the reciprocal method of sequential suturing hepatic parenchyma and
dissecting using Harmonic scalpel for left lateral hepatectomy was performed
for 4 patients. The mean hospital stay was 7 days (5-16 days). Postoperative
complications occurred in 2 patients (11.8%, intraabdominal bleeding in 1,
and severe pulmonary infection in 1), which were managed conservatively. The
mortality rate was 0%.
Conclusions: Robotic hepatectomy is safe, feasible and efficacious. Exploration of
innovative techniques compatible to robotic surgical system, such as bleeding-
control maneuver, is mandatory for future robotic liver resections.
S018: ROBOTIC SLEEVE GASTRECTOMY. A BETTER APPROACH FOR
THE UPPER GASTRIC DISSECTION. Jose Manuel Fort, PhD, Ramon
Vilallonga, PhD, Manel Armengol, PhD Universitary Hospital Vall d’Hebron.
Barcelona.
Objective: The application of robotic techniques has been reported for bariatric
operations like laparoscopic Roux-en-Y gastric bypass and laparoscopic
adjustable gastric banding, and more recently (august 2010) for LSG. Novel
techniques such as laparoscopic sleeve gastrectomy (LSG) are now used for the
treatment of morbid obesity. In fact, the only publish article to our knowledge
has been in august 2010. There is now enough experience with LSG in our
group and we had the possibility to begin robotic sleeve gastrectomy. We report
herein our initial experience with LSG performed with the use of the Da Vinci
surgical system where we have found to be easy, feasible especially in the upper
gastric part.
Method: Eighteen consecutive patients underwent LSG with the use of the Da
Vinci surgical system by the same surgical team. Surgical techniques followed
the principles of standard LSG. We used three 12 mm standard trocars and
a 8mm DaVinci trocar to perform this novel technique. The 8-mm metallic
robotic ports were inserted through the standard, disposable 12-mm trocars.
Preparation of the stomach was performed by the console surgeon alone and its
division with the staplers by the patient-side surgeon. We completed a sleeve
gastrectomy at 2 or 5 cm from the pylorus with a 36F boggie inside the stomach
and performing stappeling through a standard 12 mm trocar. A complete robotic
prolene® suture for reinforcment. The upper GI part is perfectly visible and
suturing becomes very easy with the Da Vinci System. A drain is finally placed
next to the sleeve.
Results: Twenty patients (2 men and 18 women) with a mean age of 44.4 years
(17-63) and a mean body mass index (BMI) of 48.0 kg/m2 were operated by
Robot. Mean total operative time (including docking time) was 104.1±15.3
min. Mean set-up time was 35 minutes and mean docking time was 6 min. There
were no conversions. Complete robotic prolene® suture for reinforcement
was performed in 14 patients. Also Seamguald® was used as reinforcements
in 6 patients. Peri-operative morbidity and mortality was zero. Mean time
for discharge was 4.16 days. We had a patient who required a conversion to
laparoscopic gastric by-pass after one month because of an unusual complication
of curling stomach. Mean BMI at 3 months post-operatively was 35.8± 25.6%.
The procedure can be completed with only one assistant and with four trocars
instead of five in LSG.
Conclusions: Robotic laparoscopic sleeve gastrectomy is a feasible and safe
approach. In experienced laparoscopic hands it is still an efficient surgical
technique for the treatment of morbid obesity. No added operating time for the
procedure has been reported. The application of robotics to this type of surgery
might have less obvious advantages than with LRYGBP but to us, the dissection
of the upper part of the stomach is easier. However, to our knowledge few
groups use the Da Vinci system in the world. Our Group has considered as a
novel and first approach before being involved in Robotic Gastric Bypass.
www.mirasurgery.org
S019: ROBOTIC RECTAL CANCER SURGERY VERSUS LAPAROSCOPIC
RECTAL CANCER SURGERY IN A SINGLE CENTER EXPERIENCE:
SHORT TERM OUTCOMES ANALYSIS Irinel Popescu, MD PhD FACS,
Victor Tomulescu, MD PhD, Catalin Vasilescu, MD PhD, Serban Vasile, MD,
Olivia Sgarbura, MD PhD, Vlad Herlea, MD PhD Fundeni Institute of Digestive
Diseases and Liver Transplantation
Introduction: Laparoscopic rectal surgery is a challenging procedure, and always
there are places for technical improvements in relation to its proximity to
delicate structures such as the pelvic nerves and the reproductive organs and
the difficulties of working in a narrow space. The dissection deep into the
pelvis to accomplish a correct total mesorectal excision (TME) and obtaining a
specimen with intact margins and a cylinder shape is also technically demanding.
Theoretically, improved visualization and dexterity using robotic endoscopic
surgical devices may benefit patients by making laparoscopic operations easier.
Methods: A series of 84 consecutive patients with laparoscopic resection
(between 1995-2010) and 52 consecutive patients with robotic resection
(between 2008-2010) for primary rectal cancer were analyzed. Hartmann’s
procedures were excluded. Clinical and pathologic outcomes were reviewed
retrospectively.
Results: In the laparoscopic group (LG), 50 anterior rectal resections (ARR),
34 abdominal perineal resections (APR) were performed while in the robotic
group(RG) there were 41 ARR and 11 APR. The median operative time was
182 min (140-220 min) in LG and 208 min (180- 300 min) in RG p=0.0002).
No statistically significant difference was noticed between the groups in terms
of conversion, morbidity, anastomotic leak and postoperative stay rates. Margin
clearance was obtained in all patients and the median number of removed lymph
nodes was similar: 11.37 in RG vs 11.07 in the LG (p=0.65) with a higher rate
of metastatic lymph node involvement in laparoscopy (p=0.0012). Blood loss
was higher in LG (150 ml vs. 100 ml; p=0.0001). There were 5 (5.9%) local
recurrences in the LG at a median follow- up of 27.5 months and 2 (3.84%) in
the RG at a median follow-up of 12 months (p=0.43).
Conclusions: Robotic surgery for rectal cancer proved to be safe and efficient.
Technological advances of robotic approach compared to laparoscopy allowed
better ergonomics, more refined dissection, easier preserving of hypogastric
nerves and less blood loss. Long term outcomes are to be assessed in prospective
randomized studies.
S020: ROBOTIC GASTRIC BYPASS: REDUCING ANASTOMOTIC
COMPLICATIONS Francois Pugin, MD, Pascal Bucher, MD, Monika Hagen,
MD, Nicolas Buchs, MD, Gilles Chassot, MD, Philippe Morel, MD University
Hospitals Geneva
Introduction: Gastric bypass is a recognised therapy for morbid obesity. The
laparoscopic approach offers the advantages of shorter hospital stays, lower
incision hernia rate, and less pulmonary complications. Nevertheless the rate of
anastomotic complications remains non-negligible, possibly related to the use of
stapling devices. The aim of this study is to evaluate if robotically "hand sewn"
anastomoses have a lower leak/stricture rate than stapled anastomoses.
Methods: Prospective study comparing laparoscopic versus robotic-assisted
gastric bypass for morbidly obese patients. The primary end-point was
anastomotic complications (leak and stricture). All patients selected for a gastric
bypass with a BMI over 40 were included in this study. Exclusion criteria were
contraindication to laparoscopy. The gastrojejunostomy and jejunostomy were
performed manually in the robotic group using the DaVinci surgical system and
with circular and linear staplers in the laparoscopic group respectively.
Results: 502 patients were included in this study (334 in the laparoscopic
group, 168 in the robotic group) with a mean age of 41 years and a mean BMI
of 44. The female to male ration was 4:1. There was a significantly lower
leak rate (0% vs 3.3%, p<0.05) and stricture rate (0% vs 6.6%, p<0.01)
in the robotic group compared to the laparoscopic group. Fewer pulmonary
complications were recorded in laparoscopic group (n =10, 3,0%) than in the
robotic group (n=7, 4.2%), but the difference was non significant. There was
no mortality in both groups.
Conclusion: In our experience the use of a robotic surgical system allows to
reduce anastomotic complication rate of minimally invasive gastric bypass.
Longer follow-up is needed to confirm these promising results. The gastric
bypass is a an excellent indication for robotics in visceral surgery.
17
Oral Abstracts
S021: COMPARATIVE EVALUATION BETWEEN THE ROBOTIC AND
OPEN ULTRA-LOW ANTERIOR RESECTION IN PATIENTS WITH
LOWER RECTAL CANCER Jin C Kim, MD, Kyung H Kim, MD, Sung S
Yang, MD, Jae Y Kwack, MD, Tae Y Chang, MD, Seok B Lim, MD Department
of Surgery, University of Ulsan College of Medicine and Asan Medical Center,
Seoul 138-736, Korea
Objective: The efficacy of robotic approach was comparatively evaluated with that
of open method in the ultralow anterior resection (uLAR) of low rectal cancers.
Patients & Methods: A total of 30 patients with robotic uLAR and 29 patients with
open uLAR were prospectively included. Both groups underwent complete
total mesorectal excision. The former group constituted the ninitial seven
patients using hybrid approach and the latter 23 patients using total robotic
uLAR. The laparoscopic abdominal dissection was performed preceding robotic
pelvic dissection in the hybrid approach. The open group included more male,
patients with preoperative chemoradiation, and infiltrating tumor compared to
the robotic group. The mean basal metabolic index (BMI) in the robotic group
was somewhat higher than that in the open group (23.5 ± 2.1 vs. 22 ± 3.2, P =
0.044).
Results: The mean operation time was longer in the robotic group compared
to the open group (232 ± 49 min vs. 116 ± 16 min, P < 0.001). However, the
mean number of harvested lymph node, level of anastomosis, start of formed
diet, postoperative complications, and hospitalization did not differ between
the two groups. The mean operation time did not differ between the hybrid and
total robotic approaches (233.1 ± 53.6 min vs. 234.5 ± 49 min, P = 0.951).
Operative complications occurred in three patients, i.e., minor rectal wall
perforation, and the internal iliac vein and marginal artery injuries, respectively.
A conversion to open surgery was performed in a case with the marginal artery
injury. Nevertheless, the robotic approach enabled excellent levator-sphincteric
dissection even in patients with narrow pelvis and high BMI.
Conclusions: The uLAR using total robotic approach can efficiently be
accomplished to achieve competent outcome, ensuring excellent operative field
and less physical burden to the surgeon. The RCT-based comparative study and
long-term follow-up may further enlighten the utility of robotic uLAR.
S022: ROBOTIC COLORECTAL PROCEDURES: OUR EXPERIENCE G
Spinoglio, MD, R Quarati, MD, F Priora, MD, LM Lenti, PHD, F Ravazzoni,
PHD, V Maglione, MD Division of Oncologic General Surgery, ASO "SS
Antonio e Biagio e Cesare Arrigo", Alessandria , Italy.
Aim: The robotic colorectal surgery enhances the advantages of laparoscopy
providing a three dimensional view, ambidextrous capability, tremor elimination,
multiple degrees of freedom instruments. Therefore we have used the robotic
system for colorectal surgery since 2005. Our results are reported below.
Methods: We performed 36 right colectomies, 36 left colectomies and 49
proctocolectomy: from March to April 2010 we used the new model of robot
da Vinci ® Si HD was introduced. For right colectomies we standardized our
technique with an initial vascular dissection and lymphadenectomy along the
mesenteric axis and subsequent colectomy with intracorporeal lateral-lateral
ileo-colic mechanical anastomosis. For left and proctocolectomies in the second
series, we standardized our procedure by using the Kim’s a trocar’s layout
and robotic steps: starting from the vascular dissection, rectal dissection in
the mesorectal plane proceeded in accordance with Heald’s total mesorectal
excision (TME) principles and then releasing the left colic flexure.
Results: Right colectomy: the mean operative time was301.2 (145-540) min.
Just one conversion occurred. Specimen length was 28.36+-11 cm(range 18-
50), the number of harvested lymphnodes was 23 +-11 (13-45). No surgical
complications occurred which required reintervention. The mean time of
discharge was 6 (range 4-13) days. Left colectomy: the mean operative time
was 336.0 (255-540) min. Three conversions occurred. There were seven
diverticulitis. Specimen length was 19.5+-10 cm (range 13-43), in case of
malignancy the number of harvested lymphnodes was 16.9 +-11 (8-43). Surgery
related morbidity was 1/36: one case of ileal occlusion by adhesions. The mean
time of discharge was 6 (range 4-15) days. Proctocolectomy: median operative
time 428 (250-650) min. Seven conversions to open procedures occurred.
Specimen length was 22.8+-5 cm (range 11-35) the number of harvested
lymphnodes was 19 (5-52). In 67% of patients a neaoadjuvant therapy was
perfomed. Surgery related morbidity was 5/49 which required a reintervention,
No death occurred. The mean time of discharge was 10 (range 8-30) days.
18
Were recorded good oncological results about proctocolectomies: after a median
follow up of 40 months the overall survival for all stage was 86.7% and the
DFS was 69.6%. One local relapse occured. No differences were reported in
comparison to a group of 24 laparoscopic rectal resections performed during
the same period with the same patient’s features, the overall survival was 95.8%
(p=0.373), the DFS was 91.7% (p=0.108), without local recurrence (p= 0.383).
Conclusions: We believe that robotic surgery is advantageous in the steps of
vascular dissection and TME. Prospective trials will be needed to validate
oncological and functional results.
S023: TELELAP ALF-X- THE FUTURE OF ABDOMINAL SURGERY (BACK
TO THE FINGERTIPS) Michael Stark, MD, Emilio Morales, SOFAR SpA The
New European Surgical Academy; Telelap ALF-X SURGICAL ROBOTICS
Department
Traditionally, surgeons have used their fingers to palpate and manipulate tissues.
When endoscopy and, later, robotic surgery were introduced, the use of the
fingertips – one of the most sensitive parts of the body – was abandoned and
sight became indirect.
To overcome this, a new surgical system, the Telelap Alf-x, has been developed.
This system combines the advantages of laparotomy and endoscopy. Among its
features are tactile sensing, a high degree of versatility, 3D vision, non-tremor
and an eye-tracking system.
In order to assess the validity of this system, experimental preclinical procedures
(hysterectomy, salpingo-oophorectomy, myomectomy, partial and radical
nephrecto¬my, total pelvic exenteration and cholecystectomy) were performed.
The parameters examined were:
1. The use of the newly designed handles, surgical arms and instruments
2. Haptic force transmission
3. Ergonomic aspects
4. Safety and reliability
5. The 3D Stereo Vision system
6. Docking time
7. Durability of the re-usable instruments
8. Capability of complex surgical steps
9. Economic aspects (all elements are reusable)
Regarding all these parameters system performance seems to be superior to
traditional endoscopic surgery.
Detailed reports concerning these parameters as well as the results compared to
common endoscopic operations and a video describing the usage of the system
will be presented. This system proved efficient, reliable and useful. Its use and
further development promise a simplification of the performance of complex
surgical procedures. The simplicity of its usage; tactile sensation and 3D vision
make surgery as similar as possible to traditional laparotomy, without its known
disadvantages, which result from the abdominal wall incision. Hence the system’s
description as a tool bringing about a “Renaissance of Abdominal Surgery”.
S024: SURGICAL, ONCOLOGIC AND FUNCTIONAL OUTCOMES IN
PATIENTS WITH A GLEASON SCORE 8 OR HIGHER UNDERGOING
ROBOTIC-ASSISTED RADICAL PROSTATECTOMY. Apostolos P Labanaris,
MD PhD, Vahudin Zugor, MD PhD, Jorn H Witt, MD PhD Department of
Urology and Pediatric Urology - Prostate Center Northwest, St. Antonius
Medical Center, Gronau, Germany
Introduction: During the past years robot-assisted radical prostatectomy (RARP)
has become profoundly popular and with the expanding experience obtained
with it the selection criteria for the procedure have also widened and included
more challenging cases. The objective of this study is to assess the surgical and
oncologic outcomes in patients with a Gleason score 8 or higher prostate cancer
(PCa) undergoing RARP.
Methods & Procedures: The records of N=2000 men who underwent RARP
at a certified robotic institute from February 2006 to April 2010 were
retrospectively reviewed. A total of N=137 patients were identified as having
a Gleason score 8 or higher. A comparison was performed between the overall
patient cohort and the aforementioned patients. The parameters analyzed
included: age, body-mass index (BMI), prostate weight, PSA values, percentage
of PCa found in the prostate specimen, skin-to-skin operative time, estimated
blood loss, minor (Clavien’s grade I–IIIa) and major complications (Clavien’s
6 TH ANNUAL MIRA CONGRESS May 11-13, 2011
 grade IIIb-IVa), length of catheterisation, pathologic stage, lymph node status,
positive margin status and continence (defined as no pad use).
Results: The median age of the patients was 63 / 65 years, median BMI 26.7 kg/
m2 / 28.3 kg/m2 and median prostate weight 56.1 gr. / 52.5 gr. The median
operative time was 156 min / 156 min and estimated blood loss was 160ml /
166ml. and. Minor complications were noted in 11.4% / 13.7% of cases, major
in 1.3% / 1.4% and the length of catheterisation was 5.5 days / 7.1 days. A
statistical difference of the parameters analyzed was observed in PSA values
10.3 ng/ml / 20.8 ng/ml (p<0.05), organ-confined disease 73.5% / 18.9%
(p<0.001), extraprostatic extension in 25.2% / 81.1% (p<0.001), percentage of
PCa found in the prostate specimen 16.1% / 38.2% (p<0.05), positive surgical
margins 8.9% / 32.8% (p<0.001) and positive lymph nodes 3.2% / 19.7%
(p<0.05). At 12 months, 92.8% / 90.5% were continent.
Conclusions: Our findings suggest that although RARP in patients with a Gleason
score 8 or higher PCa is a safe surgical procedure with limited complications
and good functional results, patients should be made aware of a potential risk
of positive surgical margins before undergoing the procedure. Despite these
oncologic outcomes observed we do not believe RRLP is a contraindication in
this cohort of patients.
S025: ROBOTIC-ASSISTED LAPAROSCOPIC LIVING DONOR
NEPHRECTOMIES : EXPERIENCE IN 100 CASES J. Hubert, MD, M
Ladriere, MD PhD, C. Waked, MD PhD, G Chopin, MD, P Eschwege, MD
PhD, P Eschwege, MD PhD, L Frimat, MD PhD, M. Kessler, MD Dept.
of Urology and Nephrology, CHU Nancy-Brabois, allée du Morvan, 54511
Vandœuvre les Nancy, France
Introduction & Objectives: Entirely robot-assisted laparoscopic donor
nephrectomies (RALDN) have been adopted for 8 years at our institution,
allowing an increase in renal donation. We here review our initial experience of
perioperative morbidity in donors and early outcomes in recipients.
Material & Methods: From January 2002 to January 2010, 100 patients : 60
female, 40 male; 86 left kidneys; mean age 46 yr; BMI 25 (>30 in 11 cases),
were operated on with the DaVinci® system, using four ports (three for the
robotic arms and one for the assistant). Collateral veins were ligated, and
the renal arteries and veins clipped, after completion of ureteral and renal
dissection. The kidney was removed via a suprapubic Pfannenstiel incision. A
complementary running suture was carried out on the arterial stump to secure
the hemostasis. Transplantation was carried out immediately afterwards.
Results: All RALDN (22 kidneys with 2 and 4 with 3 arteries) were carried
out entirely laparoscopically, without complications and with minimal blood
loss (mean Hb decrease 0.7 g/dl ; no transfusion). Surgery time, warm and
cold ischemia times were 177 min 4,98 min and 202 min, respectively. Post-
operative complications : 2 wound infection, 1 cholecystitis, 2 phlebitis and
2 peripheral embolism, 1 pyelonephritis, 1 chylous ascitis. Pre-op / 1 month
creatinine : 90±17 / 110 ±20 μmol/l. Average hospital stay: 4.3 days.
Recipients: mean age 43 Yr, 64 male, BMI 24; None but two (only 1 dialysis
session required) of the transplant recipients had delayed graft function.
Mean recipient creatinine clearance at 6 and 12 months: 56.7 & 57.5 ml/min.
Recipients complications comprised 2 phlebitis, 1 peripheral embolism, 3
cystitis ; 1 hematoma, 1 lymphocele and 4 ureteral necrosis required surgical
treatment.
Conclusions: RALDN can be safely carried out, with excellent short and long
term results for both donor and recipient. Robotics enhances the laparoscopist’s
skills and enables the surgeon to dissect meticulously and to prevent problematic
bleeding more easily while allowing the surgeon to work under better
ergonomic conditions.
S026: ROBOT-ASSISTED PARTIAL NEPHRECTOMY (RAPN).
EXPERIENCE IN 60 CASES. E Barbier, PE Theveniaud, N Hubert, MD,
P Eschwege, MD PhD, J Hubert, MD PhD Urology Dept, CHU de Nancy-
Brabois. Allée du Morvan, 54511 VANDOEUVRE-LES-NANCY, France
Introduction: Laparoscopic partial nephrectomy (LPN) is an accepted alternative
to open partial nephrectomy but requires a steep learning curve and is still
a challenging procedure that only leading teams have developed routinely.
Robotics may improve the different operative steps and allow to perform it more
easily and in more complex cases. We report our 5 years experience in robotic-
assisted LPN (RAPN).
www.mirasurgery.org
Material & Methods: From 03/05 to 04/10, 60 patients (39 M/21 W; 27 right and
33 left kidneys; mean age 60 yr) underwent RAPN with the DaVinci® system :
patients in a 60° flank position, 5 transperitoneal ports were used (2x12, 2x10,
1x5 mm). The artery was clamped with a bulldog before incising the renal
parenchyma with the cold scissors. After removing the specimen, 4/0 resorbable
stitches were applied to the main vessels and calyx. Complementary sealant
(BioGlue®, Tachosil®) was applied to the renal parenchyma, before releasing
the clamp. Additional parenchymal suture was applied if necessary. Gerota’s
fascia was sutured in order to retroperitonealize the kidney. No suction drain
was used.
Results: Mean tumor size : 26 mm ; ischemic time 28 min; blood loss was
minimal (no transfusion). CT scans performed within the first postoperative
week showed no hematoma and good renal function without urinary leak.
Histology showed 49 carcinomas, 7 oncocytomas, 4 AML. All surgical margins
were negative.
Complications : thrombo-embolism (2), urinary infection (2). 2 arterial aneurism
required selective embolization. At 20 months mean follow-up, no recurrence
was observed.
Conclusions: Owing to the benefits of 3D vision and the seven degrees of
freedom of the instruments offered with robotics, the surgeon can perform
complex procedures such as RAPN more easily than in standard laparoscopy.
Our promising results need to be confirmed by further comparative series, but
robotics may have an impact on partial nephrectomy similar to its impact on
prostatectomy.
S027: ROBOTIC ASSISTED LAPAROSCOPIC TRANSPERITONEAL
PYELOPLASTY : 10 YEARS EXPERIENCE, 100 CASES J. Hubert, MD,
M Chammas, MD, C. Egrot, MD, N Hubert, MD, P Eschwege, MD PhD, J
Hubert Department of Urology, CHU Nancy-Brabois 54511 VANDŒUVRE les
NANCY, FRANCE.
Introduction: Dismembered pyeloplasty is the gold standard for uretero-pelvic
junction syndrome. Laparoscopic dismembered pyeloplasty has been developed
but is a challenging procedure, which can be facilitated by robotic assistance.
Our objective is to evaluate the results of laparoscopic robotic pyeloplasty which
we developed in 2000 in experimental surgery and has become the standard
procedure in our institution since 10 years.
Material & Methods : from November 2001 to January 2007, 100
transperitoneal laparoscopic robotic assisted pyeloplasties for UPJ obstruction
were performed in 99 patients (58 female, 41 male, mean age 38.4 yr) : 36
left/64 right ; one bilateral). This was a primary treatment in 92 cases, a
2nd approach in 6; 3rd in one and 4th in one cases. Four ports were used:
3 for the robotic arms (1x12, 2x10 mm) and one (12 mm) for the assistant.
The retroperitoneal incision was minimal in all cases. Anastomosis was
completed with 6/0 running sutures and a ureteral JJ stent was introduced
peroperatively. No suction drain was used. Gerota’s fascia was sutured in
order to retroperitonealize the anastomosis. Clinical control and IVU with
lasix® were performed 3 and 12 months after surgery.
Results: All the pyeloplasties were completed laparoscopically with the robot.
There was 1 open conversion (# 20). An inferior polar pedicle had to be
uncrossed in 58 cases. Mean operative time was 118.5 min (including antegrade
JJ placement) ; mean suturing time 33.7 min ; blood loss was minimal (<40 ml);
mean hospital stay 5.23 days. Bladder catheter was removed at day 3.1. There
were 5 post-operative cystitis which resolved with antibiotic treatment. Average
length of follow-up was 23.7 months. At 3 and 12 months follow-up all the
patients were clinically improved, and of the 67 and 43 available IVUs there was
a 93% and 97 % improvement respectively.
Conclusion: Our clinical results for robotic-assisted Anderson-Hynes pyeloplasty
appear to be at least equivalent to those obtained in open surgery. The technique
was improved over the years and is now standardized. Instruments are limited
to 3 (bipolar forceps, hot scissors, microforceps) in order to reduce the costs.
Bladder catheter and JJ stent are removed after 2 and 15 days respectively.
Minimal invasive dissection, quality of the sutures, facilitation of all the
technical steps, reproducibility and ergonomy are the major advantages of
robotic assistance.
19
Oral Abstracts
S028: ROBOTIC PROSTATECTOMY. FEASIBLE AND SAFE IN PATIENTS
WITH PREVIOUS ABDOMINAL SURGERY. Apostolos P Labanaris, MD
PhD, Vahudin Zugor, MD PhD, Jorn H Witt, MD PhD Department of Urology
and Pediatric Urology, Prostate Center Northwest, St. Antonius Medical
Center, Gronau, Germany
Introduction: With the advent and expanding experience obtained with robot-
assisted laparoscopic radical prostatectomy (RALP), the capabilities of this
technique and selection criteria for the procedure have also widened and
included more challenging cases. The objective of this study is to evaluate the
surgical, oncologic and functional outcomes in patients with previous abdominal
surgery undergoing RALP.
Methods & Procedures: The records of N=2000 men who underwent RALP
at a certified robotic institute from February 2006 to April 2010 were
retrospectively reviewed. A total of N=160 (8%) patients had undergone a
previous abdominal operation. A comparison was performed between the
overall patient cohort and the aforementioned patients. The parameters analyzed
included: age, body-mass index (BMI), prostate size, PSA values, bilateral
neurovascular bundle (NVB) preservation, Gleason score, pathologic stage,
positive surgical margins (PSM), percentage of prostate cancer (PCa) found in
the specimen, blood loss, minor (Clavien’s grade I-IIIa) and major complications
(Clavien’s grade IIIb-IVa), skin-to-skin operative time, continence (defined as
no pad use) and potency (defined as erections sufficient for penetration with or
without phosphodiesterase inhibitors) in 12 months.
Results: N=56 patients (35%) had undergone previous unilateral inguinal
hernia repair (N=34 cases with mesh), N=40 (25%) previous bilateral
inguinal hernia repair (N=32 cases with mesh). N=10 (6.2%) previous gastric
operation, N=24 (15%) previous appendectomy, N=16 (10%) previous
intestine resection and N=10 (10%) umbilical hernia repair with mesh. The
age of the patients was 63 / 64 years old , BMI 26.7 kg/m2 / 27.9 kg/m2 and
prostate weight 56.1 gr. / 52.9 gr. PSA values were 10.3 ng/ml / 11.8 ng/
ml. NVB preservation was performed in 65.7% / 36.8% of cases. A Gleason
score < 7 was noted in 42.8% / 25%, a Gleason score 7 in 47.7% / 70% and
a Gleason score > 7 in 9.5% / 5 %. PCa was confined in 74% / 60% and
locally extended in 26% / 40% of patients. The percentage of PCa found in
the prostate specimen was 16.1% / 18.9% and positive surgical margins were
encountered in 8.9% / 5%. The estimated blood loss was 160ml / 186ml and
median operative time was 156 min / 171 min. Minor complications were
noted in 11.4% / 14,3% of cases and major in 1.3% / 3,75%. The length of
catheterisation was 5.5 days / 5.7 days. At 12 months, 92.8% / 86.2% were
continent and 66.2% /58,7% of preoperative potent patients who underwent
NVB preservation were potent.
Conclusions: RALP in patients with previous abdominal surgery is feasible and
safe. Although this patient cohort can still pose increased challenges even to
experienced operators, the surgical, oncologic and functional outcomes are
similar to patients without a history of previous abdominal surgery.
S029: KEY AREAS IN THE LEARNING CURVE FOR ROBOTIC
UROLOGICAL SURGERY: A SPANISH MULTICENTRE SURVEY Jesus
Moreno Sierra, MD PhD, Elena Ortiz Oshiro, MD PhD, Isabel Galante Romo,
PhD, Jose Luis Senovilla, PhD, Ivan Mansilla Garcia, Maria Escudero Romo,
Angel Silmi Moyano, MD PhD Hospital Clinico San Carlos - Universidad
Complutense de Madrid
Introduction: The number of robotic-assisted procedures performed in Spain
is rapidly increasing despite a lack of consensus criteria for training and
credentialing. This national multicenter study was designed to analyze the
different areas of the robotic urological surgery learning curve.
Material & Methods: A questionnaire was sent to all 13 urology units in Spain with
an active robotics programme requesting information on training and problems
encountered.
Results: In most centres, training programmes were animal-based; cadavers
were used at only 2. Prior experience in open and/or laparoscopic surgery was
reported by 10 of the groups (76.9%), and experience only in open surgery
by 2 (15.4%) or robotic surgery alone by 1 (7.7 %). The procedure with
which the robotics programme was started in all 13 participating units was
radical prostatectomy. The number of cases needed to complete the learning
curve for this procedure was: 20 to 25 cases according to 8 (61.5%) surgery
20
teams, 26 to 36 cases according to 3 (23.1%) and over 37 cases according to
2 (15.4%). The greatest technical difficulties reported when performing a
radical prostatectomy were: robot preparation in 2 (15.4%) cases, sparing
the neurovascular bundles in 2 (15.4 %), identifying the bladder neck in 5
(38.4%) and identifying and dissecting the seminal vesicles in 7 (53.8%).
CONCLUSIONS Up to March 26, 2010, 1692 operations, mostly radical
prostatectomies, were conducted using the da Vinci robot in our country. This
questionnaire served to identify the main problems encountered during the
installing of a robotic urological surgery programme.
S030: ROBOTIC MITRAL VALVE REPLACEMENT Changqing Gao, MD PLA
General Hospital
Background: Since 2007, we have performed over 380 cases of robotic cardiac
operations, in which robotic mitral valve surgery was performed in 66 cases.
In this present, we determined the safety and efficacy of robotic mitral valve
replacement using robotic technology.
Methods: From January 2007 through August 2010, 66 patients underwent
robotic mitral valve repair/repacement. Mean age was 48.3±14.8 (range 19–70
years) years and 75% were male, in which 22 patients with mitral valve stenosis
underwent mitral valve repacement. Surgical approach was through 4 right chest
ports with femoral perfusion, aortic occlusion was performed with Chitwood
crossclamp, and antegrade cardioplegia was administered directly via anterior
chest. Via 3 port incisions in the right chest and 2.5 to 3.0 cm working port, all
the procedures were completed with the da Vinci S robot.
Results: All patients had successful robotic surgery. Mitral valve replacement
was in 22 patients, 16 of which had mechanical valve, 6 had tissue valve.
Mitral valve repair was performed in 44 patients. The mean CPB time and
aortic crossclamp time were 137.1±21.9 (105 to 168) min and 99.3±17.4
(80 to 133) min, respectively. There no operative deaths, stroke, or other
complications. There were no incisional conversions. All patients were followed
up Echocardiographically.
Conclusions: Totally endoscopic mitral repacement can be performed safely with
robotic technology in selected patients, and surgical results are excellent.
S031: MID-TERM FOLLOW UP AFTER ROBOTICALLY
ASSISTED TOTALLY ENDOSCOPIC REPAIR OF INTRAATRIAL
COMMUNICATIONS Nikolaos Bonaros, Stepan Cerny, Felix Weidinger,
Christoph Steger, Martin Michel, Silvana Mueller, Thomas Bartel, Johannes
Bonatti, Thomas Schachner Department iof Cardiac Surgery, Innsbruck Medical
University
Background: Repair of atrial septal defects is increasingly performed via mini-
thoracotomy or in a totally endoscopic fashion using robotic technology.
Perioperative results of small series of totally endscopic ASD-repair have been
reported in the literature but the long-term results of the procedure are still
unknown.
Methods: Seventy two patients (21 male, 51 females, median age 38 (16-
62)) were operated at two institutions using the Da Vinci robotic system.
Pathology of interatrial communication included an atrial septal defect II in
56 patients, a patent foramen ovale in 15 patients and a sinus venosus defect
in 1 patient. Nine of the patients had a malpositioning of an atrial septal
occluder which had to be surgically removed. Twenty nine patients received
a patch reconstruction and 43 of the patients had a direct closure. The major
perioperative and mid-term results were evaluated by echocardiography as
well as clinical follow-up.
Results: Median operation time was 310 min (186-650), cardiopulmonary bypass
time was 135 min (55-269), and aortic cross clamp time was 70 min (33-164).
One conversion to mini-thoracotomy was needed. Two patients had to be
reoperated due to residual shunt detected before discharge. The mean follow-up
was 29 months (0.25-94). No stroke, or other major cardiac event was reported
during follow-up. The median NYHA classification was 1 (1-3) during follow-up
and the median ejection fraction was 70% (65-80). No additional residual shunt
was detected after discharge.
Conclusions: The midterm resuls of robotically assisted totally endoscopic atrial
septel defect repair are very satisfactory and well comparable with conventional
and mini-thoracotomy approaches. Complex defects including removal of
malpositioned occluders can be repaired using endoscopic methods.
6 TH ANNUAL MIRA CONGRESS May 11-13, 2011
 S032: ROBOTIC TOTALLY ENDOSCOPIC CORONARY ARTERY
BYPASS GRAFTING ON THE ARRESTED HEART - TWO CENTERS’
EXPERIENCE WITH 305 CASES Eric J Lehr, MD PhD, Thomas Schachner,
MD, Nikolaos Bonaros, MD, Dominik Wiedemann, MD, Felix Weidinger, MD,
David Zimrin, MD, Bartley Griffith, MD, Johannes Bonatti, MD University of
Maryland School of Medicine, Medizinische Universitöt Innsbruck
Objectives: Robotically assisted totally endoscopic coronary artery bypass grafting
(TECAB) is emerging as an advanced minimally invasive method of surgical
coronary revascularization. The aim of this study is to review the surgical and
mid-term outcomes of TECAB performed on the arrested heart.
Methods: Between October 2001 and August 2010, 305 patients (age 60 [range
37 – 83], 229 [75.1%] male) all with low grades of systemic atherosclerosis)
underwent arrested heart TECAB by three surgeons at two institutions. All
operations were performed with a surgical robot through 4 or 5 ports using
femoral cannulation and cardioplegic arrest delivered by an endoaortic occlusion
balloon. A total of 387 grafts were placed with 76 patients undergoing double
vessel TECAB and a triple bypass grafting procedure was performed in 3
patients. TECAB was combined with a planned percutaneous intervention in 115
patients as part of a hybrid revascularization strategy.
Results: There were no 30-day mortalities. Conversion to mini thoracotomy or
sternotomy was required in 38 (12.5%) patients. Twenty-two (7.2%) patients
underwent revision for bleeding, most commonly at the port sites. Intra-aortic
balloon pump for postoperative support was placed in 4 (1.3%) patients. Only 38
(12.5%) patients developed atrial fibrillation and deep thoracic wound infection
occurred in a single (0.32%) patient. Postoperative ventilation time was 8 hours
(0 – 349), duration of ICU stay was 20 hours (11 – 1048) and hospital length
of stay was 6 days (3 – 54). There were 3 (0.98%) strokes and 2 (0.66%) aortic
dissections. Hemofiltration or hemodialysis was necessary in 3 (0.98%) patients.
Follow up was complete in 294 (96.4%) cases. Early return to everyday activities
after hospital discharge was noted: time to walking outside was 7 days (1 – 180),
time to restarting general household activities was 14 days (2 – 360) and time
to full recovery and resuming vigorous activities was 60 days (3-720). Survival,
freedom from angina, and freedom from major adverse cardiac and cerebral events
at five years was 99.5%, 90.2%, and 80.9% respectively.
Conclusions: TECAB performed using remote access perfusion and cardioplegic
arrest appears to be safe in selected patients. A major benefit is early return to
normal activities. Intermediate term results are comparable to conventional
CABG.
S033: SEQUENTIAL CORONARY BYPASS GRAFTS FOR ROBOTICALLY
ASSISTED TOTALLY ENDOSCOPIC SURGICAL REVASCULARIZATION
OF MULTIVESSEL CORONARY ARTERY DISEASE Eric J Lehr, MD PhD,
Thomas Schachner, MD, Nikolaos Bonaros, MD, Dominik Wiedemann, MD,
Felix Weidinger, MD, Andreas R de Biasi, BS, Alina Grigore, MD, Mark Vesely,
MD, Griffith Bartley, MD, Johannes Bonatti, MD University of Maryland
School of Medicine, Medizinische Universitöt Innsbruck
Objectives: Reported benefits of sequential coronary grafts that are advantageous
in robotically assisted totally endoscopic coronary artery bypass grafting
(TECAB) include conservation of conduit, reduced dependence on proximal
aortic anastomoses, improved flow with increased runoff, more complete
revascularization and long-term patency equivalent to single ITA grafting. The
aim of this study is to review the surgical outcomes of sequential coronary
bypass grafts performed completely endoscopically with robotic assistance.
Methods: Sequential grafts were performed in 32 (age 65 [range 43 - 73], 23
[72%] male) of 387 patients undergoing TECAB at 2 institutions by 4 surgeons,
between October 2001 and August 2010. Grafting strategies included 29 double
(28 left internal mammary (LIMA) to left anterior descending (LAD) and
diagonal branch; 1 LIMA-obtuse marginal (OM) -OM or ramus) and 3 triple (2
RIMA LAD, LIMA OM-OM or ramus; 1LIMA LAD, axillocoronary saphenous
vein graft ramus-OM1) vessel procedures. All operations were performed in
a completely endoscopic fashion through 4 or 5 ports using a surgical robot.
The internal mammary arteries were harvested using a skeletonized technique.
Cardiopulmonary bypass was provided via femoral cannulation and cardioplegic
arrest achieved with an endoaortic occlusion balloon. On-table post TECAB
angiography was performed in 11 (34%) cases. TECAB was combined with
a planned percutaneous intervention in 5 (15.6%) patients as part of a hybrid
revascularization strategy.
www.mirasurgery.org
Results: Interventions were completed endoscopically in 27 (84%) patients
and conversion to mini thoracotomy or sternotomy was required in 5 (16%)
patients. Reasons for conversion included evacuation of clot from the pleural
space, anastomotic stenosis identified on intraoperative angiogram, anastomotic
bleeding, kinking of the graft at the middle anastomosis and intramural
hematoma of LIMA. Total procedure time including on-table angiography was
349(185 - 625) minutes. Cardiopulmonary bypass and crossclamp times were
158 (88 - 380) minutes and 110 (32-231) minutes respectively. Three (9%)
patients underwent revision for bleeding, most commonly at the port sites.
Conclusions: Multivessel TECAB using sequential bypass grafting strategies is
feasible. These techniques broaden the spectrum of coronary artery disease
suitable for robotically-assisted totally endoscopic revascularization.
S034: ROBOTIC THORACOSCOPIC FIRST RIB RESECTION -
PRESENTATION OF A SERIES OF PATIENTS Farid Gharagozloo, Marc
Margolis, MD, Eric Strother, CSA, Barbara Tempesta, CRNP Washington
Institute Of Thoracic And Cardiovascular Surgery; The George Washington
University Medical Center
Objectives: First rib resection is the most effective treatment for Paget-Shroetter
Syndrome (thrombosis of the axillary-subclavian vein). Previously described
techniques have included transaxillary, transthoracic, and infra/supraclavicular
approaches. These approaches are associated with an incidence of incomplete
rib resection and neurovascular complications. We report a minimally invasive
robotic thoracoscopic approach for resection of the first rib through the chest
without dissection of the extra thoracic structures.
Methods: Over a 10 month period, 10 robotic first rib resections were performed
in 6 patients Pre-operative studies included CT scan of chest and bilateral
angiography. The robot was introduced through three 2 cm incisions. The first rib
was dissected using the robot. The right robotic arm was removed and replaced
with a long thoracoscopic 6 mm kerasin which was used to divide the rib between
the subclavian artery and vein. Following the division of the rib, the right robotic
arm was re-positioned and the remainder of the procedure was performed
robotically. The division of the rib at its midpoint allowed for the rib to be pivoted
on the sternal and vertebral joints respectively. The rib was then dissected from
the scalene muscles and disarticulated at the respective joint. Success of the first
rib resection and relief of thoracic outlet syndrome was assessed by subjective
symptom relief, objective physical examination, and post-operative angiography.
Results: There were 10 total procedures in 6 patients with 4 of the patients
having staged bilateral first rib resections. bilateral procedures. There were
4 men and 2 women. Mean age was 37 years. 9/10 had anterior thoracic
outlet syndrome with obstruction of the subclavian vein (Paget-Shroetter
Syndrome). Immediate decompression of the subclavian vein and decrease in
upper extremity swelling was seen in 10/10 patients (100%). Post-op venogram
revealed a patent subclavian vein in all patients. Anti-coagulation was continued
in 4-5/10 patients based on the presence of pre-op thrombus in the subclavian
vein. There were no intra-operative or post-operative complications.
Conclusions: Robotic thoracoscopic first rib resection is feasible. It represents
an ideal approach to the resection of the first rib and scalenectomy through the
chest thereby obviating the neurovascular complications that are associated with
the transaxillary and supraclavicular approaches.
S035: ROBOTIC CARDIAC SURGERY IN GREECE Aristotelis Panos, PhD
FECTS FMH, Fotis Milas, MD, Sylvio Vlad, MD 3rd Clinic for Cardiac Surgery,
Hygeia Hospital, Athens, Greece. La Tour Hospital, Geneva, Switzerland
Objectives: We report our institutional experience with robotic-enhanced cardiac
surgery.
Methods: Patients undergoing robotic enhanced (n=16) cardiac surgery were
prospectively included between February 2008 and October 2010. The
feasibility, safety and echocardiographic follow-up were evaluated.
Results: 16 patients with a median age of 48 years old (range 24-75) underwent
robotic-enhanced cardiac surgery. All the patients were operated with the da Vinci
S robotic system. Procedures performed were mitral valve repair in 8 patients
(50%), tricuspid valve repair in 2 patients (12.5%), atrial septal defect closure in
2 patients (12.5%) and single vessel (LIMA/LAD) TECABG (total endoscopic
coronary artery bypass graft) in 4 patients (25%). No patient required conversion
to sternotomy. There was no operative mortality. Mean blood transfusion was
1.6 packages/patient. No neurological, vascular or wound complication was
21
Oral Abstracts
observed. Mean CPB and aortic cross clamping were 140±28min and 118±25
min respectively. TECABG patients were operated on beating heart and off pump.
Mean ICU stay was 1.5±0.7 days. No patient required reoperation. Follow-up
ranged from 2-34 months, during which all of the patients remained with trace
of mitral valve regurgitation in all the mitral repair patients and mild tricuspid
valve regurgitation in all the tricuspid repair patients. All the atrial septal defect
patients were successfully closed. Postoperatively all the coronary patients
became completely asymptomatic and coronary angiogram or coronary computed
tomography, performed 2-6 months post-operatively, did demonstrate a very
nicely patent LIMA to LAD anastomose.
Conclusion: Mitral and tricuspid valve repair, ASD closure and single TECABG can
be safely performed, with excellent and durable results in a wide range of patients
in routine surgical settings. Low blood transfusion rate, short hospital stay and the
avoidance of wound complication are the main advantages of this approach.
S036: SENTINEL LYMPH NODE MAPPING IN PATIENTS WITH
ENDOMETRIAL CANCER UNDERGOING ROBOTICALLY ASSISTED OR
STANDARD LAPAROSCOPIC PROCEDURES Mario M Leitao, MD, Fady
Khoury-Collado, MD, Ginger J Gardner, MD, Elizabeth Jewell, MD, Carol L
Brown, Yukio Sonoda, MD, Douglas A Levine, MD, Richard R Barakat, MD,
Nadeem R Abu-Rustum, MD Memorial Sloan-Kettering Cancer Center
Objective: To determine the feasibility of incorporating sentinel lymph node
(SLN) mapping into robotically assisted laparoscopic (RBT) and standard
transperitoneal laparoscopic (LSC) procedures in patients with newly diagnosed
endometrial cancer.
Methods: All cases with a preoperative endometrial cancer diagnosis that underwent
attempted SLN mapping during an RBT or LSC procedure without requiring
conversion to laparotomy from 9/25/05 to 8/25/10 were identified. Various
clinicopathologic data were abstracted. Time to complete the SLN mapping was
captured during RBT but not during LSC. Appropriate statistical tests were used.
Results: We identified 270 total cases (119 RBTs and 151 LSCs). SLN mapping
was performed using only blue dye in 223 cases (83%). Isosulfan blue dye
was used in 249 cases (92%). The site of dye injection was the cervix only in
248 cases (92%). SLNs were identified in 224 cases (83%). The nodal basin
distribution of the identified SLNs was: right pelvis only (n=51; 23%), left
pelvis only (n=32; 14%), bilateral pelvis (n=133; 59%), pelvis and aortic (n=6;
3%), and aortic only (n=2; 1%). SLNs were identified in 136/151 (90%) LSCs
compared to 88/119 (74%) RBTs (P<0.001). SLN mapping in all RBT cases
was done utilizing only cervical injections of blue dye. The median time to
perform SLN mapping robotically was 20 minutes (range, 5-65 min). Successful
SLN identification was based on surgeon experience with SLN (P<0.001),
and the most experienced surgeon performed LSC exclusively. The nodal
basin distribution of identified SLNs was similar for RBT and LSC (P=0.4).
The median BMI was 32.6 kg/m2 (range, 18.2-66) for the failed mapping
cases compared to 28.3 kg/m2 (range, 18.3-49.7) for the successfully mapped
cases (P=0.003) irrespective of surgical approach. Identification of SLNs was
not associated with uterine weight, tumor histology, tumor grade, or use of
preoperative lymphoscintigraphy.
Conclusions: SLN mapping is feasible, and can be easily incorporated into the
management of patients with endometrial cancer undergoing both RBT and
LSC procedures. SLN mapping can be performed in a reasonable amount of
time. The use of preoperative planar lymphoscintigraphy does not appear to be
necessary. Improvement in SLN identification, accuracy of SLN, and long-term
outcomes in this cohort of patients will require further study.
S037: A COMPARISON OF PERIOPERATIVE OUTCOMES BETWEEN
ROBOTIC AND OPEN HYSTERECTOMY FOR VERY ENLARGED UTERI
Fiona Lindo, MD, Taryn Gallo, MD, Masoud Azodi, MD, Dan-Arin Silasi, MD
Yale New Haven Health / Bridgeport Hospital
Study Objective: To examine the outcomes in patients with myomatous uteri
weighing in excess of 1000 grams who underwent hysterectomy by two
modalities: using the robotic system or by laparotomy.
Methods: All patients who underwent robotic hysterectomy for uteri of at least
1000 grams at our institution from June 2007 to March 2010 were identified
and a retrospective chart review was performed. These patients were matched
to controls by body mass index (BMI) and uterine weight and the postoperative
outcomes in both groups were analyzed and compared.
22
Results: Twenty-two patients with uteri weighing in excess of 1000 grams
underwent hysterectomy with the robotic system. The mean age of the robotic
patients was 48 years (range 39–65 years) and 46 years in the laparotomy
group (range 39–59 years). The mean BMI was 31.9 kg/m2 (range 18.5–56.3
kg/m2) and the uterine weight was 1467 gms (range 1000-3563 gms) in the
robotic group versus 30.9 kg/m2 (range 18–41 kg/m2) and 1478 gms (range
1000-3570 gms) in the open surgery group. These results were not statistically
significant. A significant difference was found for the following parameters: the
mean operating time was 255 minutes (range 180-338 minutes) for the robotic
surgery group vs 167 minutes (range xxx-xxx minutes) in the laparotomy
group (p=0.003). The mean blood loss recorded was 211 mL (100-1000 mL)
for robotic surgery vs 386 mL (150-800 mL) for open abdominal surgery
(p=0.014). Eighteen / 22 (82%) robotic patients were discharged from the
hospital on postoperative day 1. There were no conversions to laparotomy.
The mean hospital stay for the robotic patients was 1.2 days and for laparotomy
patients was 2.8 days (p=0.0001).
Conclusion: Robotic hysterectomy for very large myomatous uteri require longer
operative times but result in shorter hospital stay and decreased intraoperative
blood loss.
S038: LEARNING CURVE FOR ROBOTIC HYSTERECTOMY: THE
HENRY FORD EXPERIENCE Mona E Orady, MD Department of Obstetrics,
Gynecology, and Women’s Health, Henry Ford Health System, Detroit,
Michigan
Objective: The objective of this study was to evaluate the magnitude and effect
of the learning curve on surgical outcomes of patients undergoing robotic
hysterectomy. Parameters that may affect the learning curve will also be assessed.
Study Design: Retrospective cohort study.
Setting: Henry Ford Health System’s community based teaching hospitals.
Patients: 240 patients underwent Robotic Hysterectomy by one of 7 surgeons
between January 2007 and December 2010. Surgeons had each performed 5-84
cases each with a median number of 29 cases per surgeon.
Interventions: Scheduled robotic assisted laparoscopic hysterectomy performed for
benign indications.
Materials & Methods: All robotic hysterectomies performed for benign indications
by the 7 surgeons who were trained and began performing the procedure at
Henry Ford Health System Hospitals, from their first case until December 2010,
were identified. Case number, patient demographics, details of the operation,
pathology, operative time (cut to close), and key outcome measures including
estimated blood loss, length of hospital stay, and details of complications were
collected for analysis. Assessment of operative time versus case number for the 7
surgeons was performed and corrections for uterine weight and body mass index
(BMI) were made. Univariate statistical analyses as well as regression using
generalized estimating equations were then performed.
Results: Analyses revealed that operative time decreases significantly for
each surgeon as case number increases, up to approximately 40 cases, after
correcting for uterine weight (p=0.006). Factors that significantly influenced
operative time and the learning curve included whether a patient had a normal
BMI (equal to 25 or less), whether a patient had a uterine weight > 250 grams,
and the expertise of the assisting surgeon (resident, fellow, or attending).
Operative time decreases by half a minute, on average, with each sequential
case (SE=0.25, p=0.044). When BMI exceeds 25, cases take an average of 18
minutes longer (SE=8.5, p=0.0338). When uterine weight is greater than 250
grams, cases take an average of 67.1 minutes longer (SE=9.6, p=<0.0001).
It takes an average of 6.5 minutes longer per case, as compared to an expert
assistant, when an attending is assisting, 13 minutes longer when a fellow
is assisting, and 19.5 minutes longer when a resident is assisting (SE=3.2,
p=0.041). In addition to decreasing operative time, a statistically significant
difference in blood loss from early to late cases (p=0.009) was noted. In
addition, there was a statistically significant decrease in length of stay from early
to late cases (p=0.0323). There was no significant difference in the incidence of
complications from early to late cases (p=0.516).
Conclusion: Operative time for robotic assisted total laparoscopic hysterectomy
decreases as surgeon’s experience increase. The operative time and learning
curve are significantly affected by the experience of the assistant surgeon,
the uterine weight, and body mass index of the patient. Blood loss and
6 TH ANNUAL MIRA CONGRESS May 11-13, 2011
 length of hospital stay for patients decrease as surgeon experience increases
but complication rates are stable throughout the learning curve. Overall, it
appears that patient safety is not compromised by the learning process for
performing robotic hysterectomy.
S039: SAFETY AND EFFICACY OF ROBOTIC MYOMECTOMY Vasiliki
Chatzirafail, MD, Michael Litos, MD PhD MRCOG, Theodoros Mitsis, MD,
Nikolaos Bardis, MD, Aristidis Bakas, MD Eyroclinic,Athens, Greece
Introduction: The optimal surgical treatment for myomas remains debatable
because of the limitations of minimally invasive techniques and the disadvantages
of laparotomy. Robot-assisted myomectomy is a recently introduced technique.
The aim of this study is to evaluate outcomes of patients who underwent robotic
myomectomy.
Methods & Procedures: Retrospective study of 46 patients undergoing robotic
myomectomy. Data included indications, patients’ characteristics, fibroid
characteristics (number, size, location), blood loss, intra operative and post
operative complications, and hospitalization time.
Results: The average age was 41 years, and the average BMI 25,8. The indication
for the myomectomy was bleeding in 12 cases, infertility in 22, pain in 4
cases and mixed symptoms in 8. A total of 81 fibroids were removed with
an average of 1,9 per case. Looking at the largest fibroid for each case, the
diameters ranged from 5 to 13 cm, with a mean of 7,6 cm and a median of
8,5 cm. Summing up the diameters of all fibroids per case, the total diameter
ranged from 5 to 28 cm, with a mean of 10.6 cm and median of 9 cm. Of all the
fibroids, 37 were posterior, 20 anterior, 12 fundal, 8 in the broad ligament, and
4 were cervical. Most of them were intramural, with 5 being predominantly
intramural-subserous and 13 intramural-submucous. A percentage of 95,8%
of the operations were uneventful. One patient required laparotomy and blood
transfusion intraoperatively (2.1%), and one operation was converted to robotic
total hysterectomy because the fibroid was paracervical and could not be
exposed (2.1%). There was one case of post operative haematoma that resolved
conservatively (2,1%), and all uncomplicated cases were discharged the first post
operative day.
Conclusion: Myomectomy can be performed effectively and safely using the Da
Vinci Robot even in cases of large and/or multiple fibroids. Time, cost and
expertise are obvious limitations, and further studies are needed for safer
conclusions.
S040: LAPAROSCOPIC VS ROBOTIC FIBROID RESECTION:
EXPERIENCE 2008-2010 Konstantinos P Mirillas, MD, Konstantinos P
Mirillas, MD, Petros C Hiridis, MD, Dimitris Bisbikis, MD, Savas C Hiridis,
MD MSc, Perikles S Chrysocheris, MD, Konstantinos M Konstantinidis, MD
PhD FACS ATHENS MEDICAL CENTER
Objective: In this study we compared 169 cases of conventional laparoscopic
fibroid removal with 24 cases performed by robotically assisted technique. This
comparative elaborate study, examines several parameters including a) duration
of surgery, b) size and number of fibroids removed, c) estimated blood loss,
d) mode of suturing, e) hospitalization and patient recovery, f) post-surgical
follow-up, pregnancy rate and outcome g) surgeon’s ergonomy.
Materials & Methods: Retrospective study of 169 laparoscopic cases vs 24 robotic
cases all operated by the same surgeon. Suturing technique used was comparable
and performed in the same surgical unit. Factors being compared in the study
were independently reviewed by the theater personnel and the surgical team.
Pathology reports were issued in every single case and were all negative.
Results: Surgical duration is significantly greater in the initial steps of robotic
surgery, however it falls dramatically within the first few cases (10), and
generally robotics are recognized to have a much steeper learning curve in
comparison to laparoscopy. Size and number of fibroids removed were equal
between the two methods but required a higher (supraumbilical) access in some
robotic cases. Suturing technique used was the same but there was a tendency
for a continuous suturing in robotics that may save time in the future. Estimated
blood loss was not statistically different among the two methods. Hospitalization
and patient recovery were equivalent but there was a tendency for less pain relief
with robotics. Postsurgical follow-up and pregnancy rates were not statistically
different but further studies and long-term follow-up is required. Finally
robotic myomectomy is more ergonomic, for both the surgeon and is especially
comfortable when side-docking since this allows uterine manipulation.
www.mirasurgery.org
Conclusions: Robotic myomectomy can be performed adequately and safely and
has a much steeper learning curve in comparison to laparoscopy. Most of the
other parameters were comparable to conventional laparoscopy. Superiority of
robotic suturing in providing stability and strength in the uterus is to be proven
with long-term follow up studies.
S041: USE OF ROBOT IN HIGH ANORECTAL MALFORMATION
Abdulrahman Albassam, MD, Abdulmonem Gado, MD, Mohammed Mallick,
MD Division of Pediatric Surgery, Department of Surgery, King Khalid
University Hospital
Introduction: Since 1980 posterior sagittal anorectoplasty for High Anorectal
Malformation (ARM) is the procedure of choice for most of Pediatric surgeons.
Laparoscopic-assisted anorectoplasty (LAARP) was introduced in 2000 by
Georgeson and is gaining popularity. Robotic surgery is an emerging field in
minimally invasive surgery. To the best of our knowledge, no report has been
published that describes the use of robot in high ARM. The aim of this study is
to report on our early experience in using robot in high ARM with emphasis on
feasibility, safety and early functional outcome.
Materials & Methods: Children who underwent robotic-assisted repair of
high ARM between April 2006 and March 2010 at King Khalid University
Hospital, Riyadh, Saudi Arabia using the Da Vinci surgical system is included.
The medical records were reviewed with respect to demographic data,
associated anomalies, techniques and operative procedure, complications,
outcome and follow-up.
Results: A total of five male infants underwent robotic-assisted repair of high
ARM. Age ranged from 4 to 11 months (mean 6.6 m). Body weight ranged
from 6.2 to 9.9 kg. (Mean 7.6 kg). Three patients have associated anomalies.
All had colostomy at birth. Pre operative distal loopgram showed rectoprostatic
fistula in 3 and rectobulbar in 2. Robotically assisted repair of high ARM was
done in all 5 patients utilizing Georgeson’s technique. The fistula was divided
and ligated in 4 patients and was left open in one. Total operative time (robotic
+ anoplasty) ranged from 2.17-5.08 hours (M 3.56h). All procedures were
successfully completed without conversion to open technique. One patient
developed left sided epididymorochitis at 3 and 6 months post operatively. All
patients had their colostomy closed . It was difficult to assess fecal continence
in two patients. Two patients who were four years old have voluntary bowel
movements with no soiling. One patient three year of age has fecal soiling and
is using laxative/enema for constipation. With respect to anoplasty there were
no stenosis, In all of them the anus was in a good position, only one patient had
partial mucosal prolapsed. Follow-up ranged between 6-36 months (mean 12m).
Conclusion: Robotically-assisted repair of high ARM is feasible and safe and offers
a good alternative to the gold standard posterior sagittal anorectoplasty for repair
of high ARM. Robotic approach has advantages over laparoscopic, that include
superior vision, easier dissection in the narrow pelvis and secure closure of
rectourethral fistula. Early results are encouraging. A larger number of patients
and a longer follow-up are needed to evaluate the outcome of this novel approach.
S042: FEASIBILITY AND ONCOLOGIC SAFETY OF TRANSORAL
ROBOTIC HYPOPHARYNGECTOMY Se-Heon Kim, MD PhD, Young Min
Park, MD, Armando De Virgilio, MD Yonsei University College of Medicine
Objectives: Conventional surgical approaches for hypopharyngeal carcinomas
have a great risk for developing treatment-related morbidity. To minimize
this morbidity, hypopharyngectomy by transoral robotic surgery (TORS) was
performed, and the efficacy and feasibility of this procedure were evaluated.
Methods: TORS was performed using da Vinci Surgical Robot (Intuitive Surgical,
Inc., Sunnyvale, CA) in 18 patients with T1 or T2 pyriform sinus cancer and
posterior pharyngeal wall cancer. FK retractor (Gyrus Medical Inc., Maple
Grove, MN) was used for transoral exposure of the lesion. A face-up 30-degree
endoscope was inserted through the oral cavity and two instrument arms were
located in both sides of the endoscope. Pyriform sinus was totally resected as a
cone-shape from the vallecular to apex region, and ipsilateral arytenoid cartilage
was saved for function preservation. The aryepiglottic fold was resected
medially. Laterally, the inner perichondrium of the thyroid cartilage was peeled
off after perichondrium was incised horizontally to make sure of the safe margin
of antero-lateral portion. The posterior margin is an inferior constrictor muscle
of the posterior pharyngeal wall. We evaluated the robotic set up time, robotic
operation time, blood loss, surgical margins, swallowing time, decannulation
time, and surgery related complications.
23
Oral Abstracts
Results: Transoral robotic hypopharyngectomy was performed successfully in
all eighteen patients. The mean robotic operation time was 62.4 minutes, and
an average of 17.5 minutes was required for the setting of the robotic system.
There was no significant perioperative complication in the cases. Swallowing
function returned to all patients within 8.3 days average. Decannulation was
carried out within an average of 6.3 days after surgery. We can confirm the
negative margins by frozen section. Average surgical margins are 7.5mm
circumferentially.
Conclusions: Transoral robotic hypopharyngectomy was feasible and ontologically
safe technique for the treatment of early hypopharyngeal cancer.
S043: IS UKA MORE ACCURATE WITH ROBOTIC ASSISTANCE?
Nicholas J Dunbar, MS, Andrew D Pearle, MD, Eduardo M Suero, MD, Sharon
Horowitz, BS, Michael A Conditt, PhD, Scott A Banks, PhD University of
Florida, Hospital for Special Surgery, MAKO Surgical Corp
Introduction: Unicompartmental knee arthroplasty (UKA) is an increasingly
attractive and clinically successful treatment for individuals with isolated
medial compartment disease who demand high levels of function. A major
challenge with UKA is to place the components accurately so they are
mechanically harmonious with the retained joint surfaces, ligaments and
capsule. Misalignment of UKA components compromises clinical outcomes
and implant longevity. Cobb et al. (JBJS-Br 2006) showed that robot-
assisted placement of UKA components was more accurate than traditional
techniques, and subsequently that the clinical outcomes were improved.
Cobb’s method, however, employed rigid intraoperative stabilization of
the bones in a stereotactic frame, which is impractical for routine clinical
use. Robotic systems have now advanced to include dynamic bone tracking
technologies so that rigid fixation is no longer required. The question is - Do
these robotic systems with dynamic bone tracking provide the same accuracy
advantages demonstrated with robotic systems with rigidly fixed bones?
Methods: We compared robot-assisted and traditionally instrumented UKA in six
bilateral pairs of cadaver specimens. In all knees, a CT-based preoperative plan
was performed to determine the ideal positions and orientations for the implant
components. Traditional manual instruments were utilized with a tissue-sparing
approach to implant one knee of each pair. A haptic robotic system acting as a
virtual cutting guide was used to perform the robot-assisted UKA, again with a
tissue-sparing approach. Postoperative CT scans were obtained from all knees,
and the 3D placement errors were quantified using 3D-to-3D registration of
implant and bone models to the reconstructed CT volumes (Fig. 1).
Results: The magnitude of femoral implant orientation errors were significantly
smaller for the robot-assisted implants compared to traditionally implanted
components (4° vs 11°, p<0.001, Table 1), but the magnitude of femoral
placement errors did not reach significance (3mm vs. 5mm, p=0.056, Table 2).
Table 1. Implant Orientation Errors
Flexion Varus Internal
Manual Instruments 5.1° 5.8° 8.3°
Robot-Assisted 1.6° 3.1° 2.2°
Table 2. Implant Placement Errors
Anterior Medial Superior
Manual Instruments 3.1mm 2.8mm 3.3mm
Robot-Assisted 2.9mm 1.2mm 1.7mm
Discussion: Well-placed UKA implants can provide durable and excellent
functional results, which is an increasingly attractive option for young and active
patients with severe compartmental osteoarthritis who wish not to have or to
delay a total knee replacement. Previous studies have demonstrated significant
improvement in implant placement accuracy and clinical results with robot-
assisted surgery using rigid bone fixation. This study demonstrates it is possible
to achieve significant accuracy improvements with robot-assisted techniques
allowing free bone movement. Additional larger trials will be required to
determine if these differences are realized in clinical populations.
24
S044: VIRTUAL REALITY ROBOTIC SURGERY SIMULATOR: MIMIC®
DV-TRAINER, A TOOL FOR CERTIFICATION ? C Perrenot, MD, M Perez,
MD, N Tran, MD, J P Jehl, J Felblinger, MD PhD, J Hubert, MD Urology Dept
& IADI, CHU Nancy-Brabois. Allée du Morvan, 54511 Vandoeuvre-Les-Nancy,
France
Introduction : Development of robotic surgery requires training and assessment
of specific skills. Training on animal model or in operating room is expensive
and exposes to medico-legal implications of the learning curve. Virtual reality
simulators are an interesting alternative, already used in laparoscopy but still under
development for robotic surgery. The aim of this study is to check the validity of
the Mimic® simulator as a tool for learning robotic surgery specific skills.
Material & Methods: A prospective study was conducted from December 2009
to March 2010, using a robotic surgery simulator dV-Trainer (MIMIC®). 75
subjects (5 experts with more than 100 robotic cases, 6 confirmed robotic
surgeons with 10 to 40 robotic cases, 8 robotic beginners, 37 surgeons and
residents, 19 nurses and medical students) were included. Five exercises
representative of robotic specific skills (camera moving, clutching, endowrist
manipulation, hand coordination and visual force feedback) were chosen. The
analysis was performed by two experts and based on quiz, on more than 1100
scores on the simulator and on videotaped similar exercises performed on an
actual Da Vinci S.
Results: Face and content validity were considered as high by most of the subjects.
Yet, some limitations about rotation, fluidity and 3D-vision were reported
by participants. Assessment of competence with the dV-Trainer was highly
reliable (correlation coefficient = 0.783). The simulator was able to significantly
differentiate five levels of ability (ANOVA p<0.05). The assessment on dV-
Trainer was overall relevant regarding concurrent validity (correlation coefficient
= 0,822). When studied separately, some criteria and exercises were medium
relevant and need improvement before being included in a credentialing program.
Conclusion: The robotic surgery simulator dV-Trainer is a reliable and valid
support tool for certification. Further studies are needed to choose the
more relevant among the 30 further developed exercises and to develop the
fundamentals in robotic surgery.
S045: DEVELOPMENT OF A SEMI-AUTOMATED ROBOT-ASSISTED
FLEXIBLE ENDOSCOPE N. van der Stap, BS, R. Reilink, MS, I.A.M.J.
Broeders, Prof dr, S. Misra, dr, S. Stramigioli, Prof dr ir MIRA, University of
Twente; Meander Medical Center.
Objective: The objective of this study is to develop a robot that can control
commonly used commercially available colonoscopes in order to make steering
easier. Colonoscopy takes a long time to master, mostly because of the difficult
steering mechanism of colonoscopes(1). When the feasibility of a nationwide
screening program was investigated in The Netherlands, one of the conclusions
was that there was a lack of specialists(2). Additionally, one of the research
directions within the Natural Orifice Transluminal Endoscopic Surgery
(NOTES) research focuses on the use of flexible endoscopes to perform surgery
without scars. One of the main problems in this research is endoscope control.
By making the steering of colonoscopes easier, a national screening program for
colorectal cancer and development of NOTES instruments may become more
feasible. We will do this by designing and testing an image processing algorithm
which steers the scope automatically, developing a prototype and testing this
prototype in a realistic environment.
Methods: An alternative way of controlling several commercially available
colonoscopes was developed. Input from trained medical specialists was
important in this development. A mechanical interface was developed such that
it can be fitted to the proximal end of commonly used flexible endoscopes. The
mechanical interface can be controlled by means of several algorithms. Two
algorithms were explored in order to facilitate image-based scope control (3).
The first one, the optical flow algorithm, uses subsequent images to determine
the motion of the environment from the camera’s point of view and correct
the endoscope in the right direction. The second one, the image intensity
algorithm, first filters the image and then calculates the centroid (lumen center)
that resembles the darkest part of the image. These algorithms were tested in
a virtual environment and used to steer the endoscope autonomously. In the
current study, these algorithms will be tested in a more realistic environment
and implemented in a prototype. This prototype is equipped with innovative
controls for situations in which the algorithm may fail to find the correct
direction (e.g. flexure, large carcinoma).
6 TH ANNUAL MIRA CONGRESS May 11-13, 2011
 Results: When compared, the image intensity algorithm turned out to be more
accurate. Furthermore, the robotically steered endoscope performed better to
the manual steering technique (it kept the lumen better centered in the image)
(3). A prototype containing an intuitive interface and automated steering for
commercially available colonoscopes was created.
Conclusions: The feasibility of an automated steering algorithm for colonoscopy
was investigated and implemented. If the colonoscopy procedure becomes
easier to learn and perform, more specialists can be trained in shorter time.
Automated steering may result in a feasible, cost-effective nationwide screening
program for colorectal cancer and can be used in NOTES instruments.
1.
Anderson, JC, et al. Factors predictive of difficult colonoscopy. 2001,
Gastrointestinal Endoscopy, Vol. 54, No.5, 558-562.
Klink, Letter to the President of the Dutch Chamber of Deputies. Betreft
2.
Standpunt darmkankerscreening, 2010, Ministry of health, www.minvws.nl.
Reilink, R, Stramigioli, S and Misra, S. Image-Based Flexible Endoscope
3.
Steering. 2010 , IEEE/RSJ International Conference on Intelligent Robots and
Systems, Taipei, 2339-2344.
S046: ADVANCED ROBOTIC MULTI-DISPLAY EDUCATIONAL SYSTEM
(ARMES), AN INNOVATIVE REAL-TIME AUDIOVISUAL MENTOR
DURING COMPLEX ROBOTIC SURGERY Yanghee Woo, MD, Kazutaka
Obama, MD PhD, Tae-il Son, MD, Hyung Il Kim, MD, Woo Jin Hyung, MD
Phd Department of Surgery, Robot and Minimally Invasive Surgery Center at
Yonsei University College of Medicine, Seoul, Korea
Introduction: Explosive scientific and technological advancements of the 21st
century are profoundly impacting surgical training world-wide. Videos,
simulators, and virtual reality modules are being integrated into training
programs with the expectation that these will minimize the cost to the patient.
The purpose of our project, Advanced Robotic Multi-display Educational System
(ARMES) was to create an innovative real-time audiovisual mentoring system
using multi-input display, TileproTM to aid in the performance of advanced
robotic surgical procedures.
Technique: As the pilot operation, we selected robotic distal gastrectomy with
gastrojejunostomy and extended lymph node dissection for the treatment of
gastric cancer. We established three-stages of ARMES development: 1) the
standardization of key operative steps; 2) the preparation of well edited short
video clips for each of the previously determined steps using our extensive
library of videos of over 350 high quality robotic gastrectomies; and 3) the
integration of these video segments into the da Vinci Robot system using
TileproTM. We identified 30 key segments of a radical gastrectomy with D2
lymph node dissection and created short video clips for ARMES. ARMES
was successfully implemented from the trocar placement to resection and
anastomosis during a robotic gastric cancer surgery.
Conclusion: We describe a novel intraoperative real-time mentor, the Advanced
Robotic Multi-display Educational System. A prospective clinical trial evaluating
the effectiveness of ARMES on training of surgeons in complex robotic
operations is planned.
S047: DEVELOPMENT OF A USER INTERFACE FOR COLONOSCOPE
CONTROL N Kuperij, BSc, R Reilink, MSc, IAMJ Broeders, Prof Dr, MP
Schwartz, Dr, S Stramigioli, Prof University of Twente, Department of
Technical Medicine, University of Twente, Enschede, The Netherlands
Introduction: The goal of this study is to enhance the colonoscopy procedure by
improving the intuitiveness of flexible endoscope tip control. For this purpose a
control interface was designed to aid the physician in performing more efficient
and effective colonoscopy which is used to diagnose colorectal cancer. Early
detection of colorectal cancer can improve the current survival rates of 50-60%
to 80-90%[1]. However, screening programs require extensive clinical resources
and diagnostic tests. Colonoscopy is considered one of the most difficult types of
flexible endoscopy procedures, yet it remains the most sensitive detection method
for colorectal cancer[2]. The advanced skills that are required to adequately steer
the endoscope call for more intuitive control. Besides simplifying and accelerating
endoscope introduction, the greater cognitive reserve that is obtained during the
procedure allows for fast and accurate diagnosis. Moreover, the lengthy learning
curve of clinicians performing colonoscopy may be reduced. Clinical ideas and
demands were intended to strongly influence prototype design, allowing optimal
clinical compatibility.
www.mirasurgery.org
Methods: A human interface is designed that connects to a motorized steering
unit attached to a flexible endoscope. The motorized unit was the result
of earlier research that facilitates this test setup[3]. This allows optimal
compatibility with the clinical situation since the colonoscope itself remains
intact. The interface was developed such that endoscope tip steering and
advancement is permitted by one hand, in contrast to the current practice in
which a minimum of two hands is needed, leaving the other hand available
for handling additional instruments (for example during polypectomy.)
The endoscopist and patient may remain in their usual position, with the
endoscopist’s dominant hand now on the grip which is around the scope. The
grip is 19 cm long and consists of two rigidly connected parts; the gripping
part and a sensor housing part for the 3DOF orientation tracker (XSens
Technologies) that was utilized to enable position controlled steering. The outer
form of the easy to hold grip was inspired on a regular handlebar, whereas the
inner structure contains a cut-out space for the scope and ribs to allow scope
gripping.
Results: A grip was constructed that yields sufficient friction to facilitate scope
advancement when squeezed, but allows the scope to slide through upon
relaxation. Position controlled steering was enabled through a 3DOF orientation
tracker. Upon rolling the grip in axial direction, the horizontal direction of the
endoscope tip was controlled. Pitching the grip resulted in movement of the
camera in vertical direction.
Conclusions: A prototype hand held interface was designed to steer a colonoscope.
Input from experienced endoscopists and supporting teams was used in order to
create a system that can easily be implemented in the clinic.
1.
Gezondheidsraad (2009) Bevolkingsonderzoek naar darmkanker. 13.
Anderson, J.C., et al., Factors predictive of difficult colonoscopy.
2.
Gastrointestinal Endoscopy, 2001. 54(5): p. 558-562.
Reilink, R., S. Stramigioli, and S. Misra, Image-Based Flexible Endoscope
3.
Steering. Proceedings IEEE/RSJ International Conference for Intelligent
Robotic Systems (Taipei, Taiwan), 2010: p. 2399-2344.
S048: ROBIN HEART - FROM VIRTUAL TO REAL SURGEON TOOLS.
Zbigniew Nawrat, MD, Pawel Kostka, PhD Foudation of Cardiac Suregry
Development
The Foundation of Cardiac Surgery Development (FCSD) realize project of
polish robot named Robin Heart (www.robinheart.pl) and mechatronic tools.
New, semi-automatic tools are in the process of emerging- our Robin Heart Uni
System. The Robin Heart Shell console is equipped with a consulting program
that makes it possible to obtain all patients diagnostic information during the
operation, as well as elements of operation planning on the screen. The virtual
operating theatre introduced in our laboratory allows surgeons to train some
elements of an operation, check the best placement of the ports in order to avoid
internal collisions. Exhausted by 3-D visualisation, this system can be helpful in
planning of a operation on a given patient.
The Robin Heart manipulator has very good and relatively large working space,
in which surgeon can select small subspace with very good isotropic kinematics’
properties for manipulating of objects with good position accuracy. System was
verified both functionally and technically. Standard technical evaluation allowed
to estimate the value of positioning resolution equal 0.1[mm]. The mile stone
of the project were an animal experiment, carried out in January 2009 (Robin
Heart model 1,2,Vision) and May 2010 (Robin Heart mc 2). The operations
were performed on pigs at the Centre of Experimental Medicine, the Silesian
Medical University in Katowice. The goal of these experiments was to show
the constructors the area of indispensable changes which will be introduced to
worked out devices before study of technology of serial production and clinical
initiating. Robin Heart system experiment carried out on pigs allowed to verify
many aspects of very complex project and was the source of hints for future
development. As a conclusions from the experiment users (surgeons) have
expressed good opinion on the ergonomics and possibilities of controlling the
robotic arms by means of the Robin Heart Shell console. The opportunities of
operating by means of the Robin Heart Uni System mechatronic tool are very
promising, as it may be mounted on the robot’s arm or controlled manually.
The Robin Heart family of Polish robots has a chance of becoming a commonly
used high-tech technical and tele-medical system facilitating the performance
of some parts of operations in minimally invasive, precise manner, safe for the
patient and the surgeon.
25
Oral Abstracts
S049: ROBOT ASSISTED- VS. CONVENTIONAL LAPAROSCOPY: A
STUDY OF THE IMPACT OF HYSTERECTOMY TYPE AND UTERINE
SIZE Gunjal Garg, Deslyn Hobson, Saima Ghazal, Ylbe Franco, Sonia Kim, S.
Gene L McNeeley, David C Kmak, Awoniyi Awonuga, Susan L Hendrix Wayne
State University/ Detroit Medical center
Objective: To comparatively analyze the outcomes associated with supra-cervical
hysterectomy and total hysterectomy, performed via robot assisted- versus
conventional laparoscopy at our institution.
Methods: Data were collected on all patients that underwent either a
laparoscopic or robotic hysterectomy between 2003 and 2010. Statistical
analysis used t-test, Pearson’s Chi-square test, and multiple regression analysis
in a forward stepwise method.
Results: A total of 699 patients were included; 574 supra-cervical hysterectomy
(524 laparoscopic and 50 robotic) and 125 total hysterectomy (48 laparoscopic and
77 robotic). There were no significant differences between the robotic and the
laparoscopic groups with regards to patient age, race, body mass index, number
of previous laparotomies, or primary pain control method, for both hysterectomy
types. Although, the mean operative times were comparable between the
robotic total hysterectomy and the laparoscopic total hysterectomy (168 vs. 183
minutes, p>0.05); it was significantly shorter for the laparoscopic supra-cervical
hysterectomy compared to the robotic supra-cervical hysterectomy (133 vs. 188
minutes, p <0.001). The estimated blood loss did not differ significantly between
the robotic supra-cervical hysterectomy and the laparoscopic supra-cervical
hysterectomy (130 vs. 143 ml, p=0.6); although, it was significantly less for the
robotic total hysterectomy compared to the laparoscopic total hysterectomy (92
vs. 171 ml, p<0.001). Pain score on the day of surgery was significantly higher
in the robotic group compared with the laparoscopic group for both supra-
cervical hysterectomy (5.1 vs. 3.0, p<0.001) and total hysterectomy (5.4 vs. 3.0,
p<0.001). There was no significant difference with regards to the complication
rate (intra-operative, immediate- and/or delayed post-operative) between the
robotic and the laparoscopic groups in patients undergoing either a supra-cervical
hysterectomy or a total hysterectomy (p>0.05). Upon stratification of the surgical
outcome data by uterine weight (<250 g or ≥ 250 g); the above mentioned trends
regarding laparoscopic versus robotic procedure were maintained in each uterine
weight category for both hysterectomy types. On a subsequent multiple regression
analysis, procedure type (laparoscopic versus robotic) was found to be an
independent predictor of operative time in supra-cervical hysterectomy(favoring
laparoscopic), estimated blood loss in total hysterectomy(favoring robotic), and
pain on day of surgery in both supra-cervical and total hysterectomy (favoring
laparoscopic), after controlling for other confounding factors such as age, race,
body mass index, previous laparotomies, uterine weight, operator experience, and
primary method of pain control (epidural vs. patient controlled analgesia).
Conclusion: Although, robotic surgery was associated with reduced blood loss
in total hysterectomy; it did not seem to confer any advantage in supra-cervical
hysterectomy, regardless of the uterine weight. Additionally, it was associated
with significantly higher pain scores than the laparoscopic procedure for both
supra-cervical and total hysterectomy.
S050: ROBOTIC-ASSISTED SALVAGE PROSTATECTOMY. SURGICAL,
ONCOLOGIC AND FUNCTIONAL OUTCOMES Apostolos P Labanaris, MD
PhD, Vahudin Zugor, MD PhD, Jorn H Witt, MD PhD Department of Urology
and Pediatric Urology - Prostate Center Northwest, St. Antonius Medical
Center, Gronau, Germany
Introduction: During the past years robot-assisted laparoscopic radical
prostatectomy (RALP) has become profoundly popular and with the expanding
experience obtained with it the selection criteria for the procedure have also
widened and included more challenging cases. The objective of this study is to
assess the surgical, oncologic and functional outcomes in patients undergoing
salvage RALP.
Methods & Procedures: The records of N=2000 men who underwent RALP
at a certified robotic institute from February 2006 to April 2010 were
retrospectively reviewed. A total of N=15 patients were identified as having
undergone salvage RALP. The parameters analyzed included: age, body-mass
index (BMI), prostate weight, PSA values, percentage of prostate cancer (PCa)
found in the prostate specimen, skin-to-skin operative time, estimated blood
loss, minor (Clavien’s grade I–IIIa) and major complications (Clavien’s grade
IIIb-IVa), length of catheterisation, pathologic stage, lymph node status, positive
margin status, and continence (defined as no pad use).
26
Results: Primary treatment was brachytherapy in n=5 ptients, HIFU in n=4,
external beam radiation in n=5 and brachytherapy and cryotherapy in n=1. The
functional status of patients preoperative was compromised. Preoperative, all
patients were impotent and exhibited significant irritative symptoms as well.
The median age of the patients was 65 years (57-73), median BMI 28.8 kg/m2
(28-37 kg/m2) and median prostate weight 42.1 gr. (23-92 gr.). The median
PSA value was 6.8 ng/ml (1.7-16 ng/ml). The median operative time was 168
min (120-220 min) and estimated blood loss was 151ml (20-350 ml). No major
complications were noted and minor complications were evident only in N=2
cases (13.3%) (urine leak identified by postoperative cystogram). The length of
catheterization was 6.5 days (5-13 days). An organ-confined disease was noted
in N=6 (40%) patients and extraprostatic extension in N=9 (60%). The median
percentage of CaP found in the prostate specimen was 27.1% (2%-84%),
positive surgical margins were noted in N=1 case (6.6%) and positive lymph
nodes in N=1 case (6.6%) as well. After a median follow up of 20.2 months (6-
53 months) 40% were continent (0 Pads/d) and 46.7% mild incontinence (1-2
Pads/d). 66.6% were free of biochemical progression.
Conclusions: Our findings suggest that salvage RALP is a safe and effective
therapeutic modality in patients with locally recurrent prostate cancer. Although
surgical and oncologic outcomes are satisfying, patients should be made aware of
suboptimal functional outcomes before undergoing the procedure.
S051: ONCOLOGICAL OUTCOMES OF ROBOTIC GASTRECTOMY FOR
GASTRIC CANCER COMPARED TO LAPAROSCOPIC GASTRECTOMY
Kazutaka Obama, MD, Woo Jin Hyung, MD PhD, Yanghee Woo, MD, Hyoung-
Il Kim, Sung Hoon Noh, MD PhD Yonsei University College of Medicine
Introduction: Robotic gastrectomy for gastric cancer has not widely accepted
yet, even though there are some reports that showed its feasibility and safety.
The oncologic safety of robotic gastrectomy for gastric cancer still remains a
concern. There is no report of long-term outcome of robotic gastrectomy for
gastric cancer. We aimed to assess the oncologic safety of robotic gastrectomy by
evaluating its long-term outcomes (survival and recurrence) with comparison to
conventional laparoscopic gastrectomy.
Patients & Methods: For retrospective cohort analyses, using a prospectively
collected database for gastric cancer the in Yonsei University Severance
Hospital, we extracted 316 robotic and 538 laparoscopic gastrectomies
performed for gastric cancer patients from July 2005 to December 2009. After
excluding operative mortality and combined operations for other cancers,
patients who had undergone 313 robotic and 524 laparoscopic gastrectomies
were compared in terms of recurrence, patterns of recurrence, and survival.
Results: Robotic gastrectomy group (RG) showed younger and more advanced disease
than laparoscopic gastrectomy group (LG). With a median follow-up period of 36
months, recurrence was 5.1% (16/313) in RG and 2.9% (15/520) in LG (p=0.100).
There was no difference in recurrence pattern in both groups. The 5-yr overall
survival rate of RG was 94.9% in the RG group and 93.8% in the LG and the hazard
ratio for death in the RG as compared to the LG was 0.87 (95% confidence interval,
0.43 to 1.78; P=0.702). The 5-yr relapse free survival rate of RG was 93.1% in the
RG group and 92.2% in the LG. When we compared the survival after stratifying by
stages, survivals of both groups were similar in each stage.
Conclusions: This large-sized study showed that robotic gastrectomy for gastric
cancer had acceptable long-term oncologic outcomes compared to laparoscopic
gastrectomy, although this is a single center study. The study provides
additional evidence suggesting that robotic gastrectomy is a good alternative
for laparoscopic gastrectomy in patients with gastric cancer, although results
of a multicenter prospective study and more long-term follow-up are needed to
provide conclusive evidence.
S052: MULTIDIMENSIONAL ANALYSES OF THE LEARNING CURVE OF
ROBOTIC GASTRECTOMY FOR GASTRIC CANCER: A COMPARISON
WITH LAPAROSCOPIC GASTRECTOMY Hyoung-Il Kim, MD, Woo Jin
Hyung, MD, Yanghee Woo, MD, Kazutaka Obama, MD, Sung Hoon Noh, MD
Department of Surgery, Institute of Gastroenterology, and Cancer Metastasis
Research Center Yonsei University College of Medicine, Seoul, Korea
Introduction: Robotic surgery for gastric cancer showed excellent clinical
results and it has been increasing. However, the learning curve of the robotic
gastrectomy has not yet been evaluated. The aim of this study was to assess
the learning curves of robotic gastrectomy using multidimensional analyses in
comparison with that of laparoscopic gastrectomy.
6 TH ANNUAL MIRA CONGRESS May 11-13, 2011
 Methods & Procedures: From May 2003 to April 2009, 883 consecutive minimally
invasive gastrectomies were performed. Excluding total gastrectomies and
combined resections, 172 robotic and 481 laparoscopic distal gastrectomies
were analyzed. The operation time was evaluated using moving average and non-
linear regression model. The success of surgery was analyzed by cumulative sum
(CUSUM) plot. The failure of surgery was defined as open conversion, lymph
nodes harvest less than 16, and perioperative morbidity and mortality. The
target failure rate was 0.1.
Results: For each robotic and laparoscopic gastrectomy group, moving average
graph indicated steady state at 95 and 270 cases respectively; non-linear
regression model indicated no definite steady state and at 267 cases respectively;
adjusted non-linear regression model indicated at 121 and 262 cases respectively.
The adjusted factors were age, sex, body mass index, reconstruction method and
extent of lymph node dissection. The CUSUM plot showed no cut-off point in
robotic gastrectomy whereas at 80 cases in laparoscopic gastrectomy.
Conclusion: The multidimensional analyses of learning curve of robotic
gastrectomy showed that an experienced laparoscopic surgeon requires fewer
cases numbers to reach steady state and successful surgical outcome is achievable
from the initial period compared with his laparoscopic gastrectomy.
S053: COMPARISON OF ROBOTICALLY ASSISTED AND STANDARD
LAPAROSCOPIC PROCEDURES IN PATIENTS WITH ENDOMETRIAL
CANCER Mario M Leitao, MD, Ginger J Gardner, MD, Gabriel Briscoe, Kevin
Santos, Elizabeth Jewell, MD, Nadeem R Abu-Rustum, MD, Carol L Brown,
MD, Dennis S Chi, MD, Yukio Sonoda, MD, Richard R Barakat, MD Memorial
Sloan-Kettering Cancer Center
Objective: To compare outcomes between robotically assisted laparoscopic (RBT)
and standard transperitoneal laparoscopic (LSC) procedures in patients with
endometrial cancer.
Methods: All cases with a preoperative endometrial cancer diagnosis scheduled
for RBT among 9 surgeons were prospectively captured from 5/1/07-6/19/10.
A consecutive cohort of cases scheduled for LSC for endometrial cancer during
the same time period among 7 surgeons were retrospectively identified. All
surgeons were experienced LSC surgeons. Fellow involvement was gradually
increased for the RBT group over time. Fellow involvement was constant in the
LSC group. Operating room time (ORT) was measured from patient arrival in
the OR to exit. Operative time (OT) was measured from skin incision to full
closure. Appropriate statistical tests were used.
Results: We identified 271 cases planned for RBT and 278 planned for LSC. Median
BMI was 28.6 kg/m2 (range, 18.6-66) and 28.2 kg/m2 (range, 16.9-57.2),
respectively. Conversion to laparotomy was necessary in 32 RBTs (12%) and 34
LSCs (12%) (P=0.9). Pelvic and para-aortic lymphadenectomy was performed in
110/239 (46%) completed RBTs and 112/244 (46%) completed LSCs (P=0.8).
Median ORT was 301 min (range, 142-613) and 253.5 min (range, 133-532),
respectively (P<0.001). Median OT was 217 min (range, 99-533) and 184.5 min
(range, 80-445), respectively (P<0.001). ORT and OT for RBTs varied among
surgeons; more experienced RBT surgeons had significantly shorter ORTs. After 40
cases per surgeon, the median times for RBT equaled those for LSC. Median pelvic,
paraaortic, and total nodal counts for RBTs were 14 (range, 3-34), 6 (range, 0-22),
and 21 (range, 7-48) compared to 16 (range 3-48), 5 (range 1-21), and 22.5 (6-57)
for LSCs (P=NS for all). Median length of hospital stay (LOS) was 1 day (range, 1-5)
for RBTs (71% discharged on Postop Day 1), and 2 days (range, 1-15) for LSCs (27%
discharged on Postop Day 1 [P<0.001]). Median estimated blood loss for RBTs was
50 ml (range, 0-400), and 100 ml (range, 0-900) for LSCs (P<0.001).
Conclusions: RBT and LSC approaches are both feasible, and both result in good
outcomes in patients with endometrial cancer. RBT was associated with longer
ORT and OT compared to LSC in a well-established and experienced LSC
program. However, ORT and OT were equal after 40 RBT cases per surgeon.
Patients who underwent an RBT had a shorter LOS. LOS may be related to
surgeon preferences and initial clinical pathways.
S054: MULTICENTER STUDY OF ROBOTIC VERSUS ENDOSCOPIC
THYROIDECTOMY FOR THYROID CANCERS: POSTOPERATIVE
OUTCOMES AND SURGEON ERGONOMIC CONSIDERATIONS Hee-Lee-
Nah Suh, MD, Jandee Lee, MD, Sang Wook Kang, MD, Jeoung Ju Jung, MD,
Un Chung Choi, MD, Jong Ho Yun, MD, Woong Youn Chung, MD PhD Ajou
University School of Medicine1, Yonsei University College of Medicine2,Won-
Kwang University College of Medicine3, Ulsan University School of Medicine
www.mirasurgery.org
Objectives: Robotic thyroidectomy has several advantages over conventional
endoscopic thyroid surgery. However, few studies have compared the robotic
and pure endoscopic thyroidectomy techniques in terms of postoperative
outcomes. Moreover, such an operative approach may cause musculoskeletal
discomfort in the surgeon, which may in turn impact patient outcome. The aim
of this multicenter study was to confirm the merits of robotic thyroidectomy by
comparing endoscopic thyroidectomy in patients with thyroid carcinomas, and
to compare physician perspectives on the musculoskeletal ergonomic parameters
associated with open, endoscopic, and robotic thyroidectomy.
Materials & Methods: Between November 2001 and June 2010, a total of 2,612
patients with thyroid carcinomas underwent at three centers by four surgeons.
Of these patients, 1,769 patients underwent robotic thyroidectomy (robotic
group), and 843 patients a conventional endoscopic thyroidectomy (endoscopic
group). These two groups were retrospectively compared with respect to patient
characteristics, operative outcomes, complications, and pathologic results.
Moreover, surgeons were surveyed to gather data on musculoskeletal discomfort
experienced during open, pure endoscopic, and robotic thyroidectomy.
Results: The patient demographics were similar in both groups. A total of 856
(32.8%) total thyroidectomy and 1274 (67.2%) less-than total thyroidectomy
were carried out. Total thyroidectomy was performed more frequently
in the robotic group (p=0.004). The groups were comparable in tumor
size, pathology, multiplicity, and bilaterality. However, tumor stage in the
robotic group were more advanced than in the endoscopic group (p=0.002).
Statistically significant differences were noted in favor of robotic vs. endoscopic
total thyroidectomy with regard to operative times (p<0.001). The total
number of retrieved central lymph nodes was greater in the robotic group
(p=0.012). The two groups showed no significant differences in terms of
intra-operative and postoperative complications. When surgeons ranked the
operative approaches in decreasing order of associated pain, 57.1% indicated
endoscopic>open>robotic, 28.6% selected open>endoscopic>robotic, and
14.3% responded endoscopic>robotic>open.
Conclusion: Robotic thyroidectomy using gasless transaxillary approach was a
feasible, safe procedure and provided good outcomes for differentiated thyroid
carcinoma patients. Moreover, for surgeons, the robotic approach resulted in
less musculoskeletal discomfort than did open or endoscopic thyroidectomy.
The present study also showed that robot technology overcame some technical
limitations associated with conventional endoscopic procedures in terms of
operation time, and lymph node retrieval.
S055: ROBOT AND LAPAROSCOPIC ASSISTED GASTRECTOMY : A
COMPARISON OF SURGICAL OUTCOMES Byunghee Kang MD, Junyoung
Kim MD, Sanguk Han MD, Department of Surgery, Ajou University, School of
Medicine, Korea
Introduction: Laparoscopic assisted gastrectomy(LAG) was widely accepted
operation technique in early gastric cancer. Recently, Robot assisted
gastrectomy(RAG) has been accepted as an alternative minimal invasive surgery.
This study aimed to evaluate the question whether RAG for treatment of gastric
cancer is feasible and safe.
Method & Procedure: We prospectively collected data and retrospectively reviewed
332 consecutive patients from Nov. 2008 to Dec. 2010. Laparoscopic or
robot assisted gastrectomy were performed by one attending surgeon at the
Ajou University Medical Center. We compared clinicopathological features,
operation time, and surgical outcome between the two procedures.
Result: 243 patients underwent LAG and 89 patients underwent RAG. 213
patients of LAG underwent distal subtotal gastrectomy and 30 patients
underwent total gastrectomy. 78 patients of RAG underwent distal subtotal
gastrectomy and 11 patients underwent total gastrectomy. RAG patients were
younger than LAG (52.97 ± 12.1 vs 58.72 ± 12.0, p<0.001). Operation time
was longer in RAG (203.82 ± 53.1 vs 171.65 ± 51.38, p<0.001). Postop
morbidity cases(14.6% in RAG vs 9.9% in LAG, p=0.225) were not significant
difference. In subtotal gastrectomy cases, more lymph nodes were harvested
in RAG (38.27 ± 16.1 vs 34.24 ± 11.9, p=0.021). But there is no significant
difference in total gastrectomy cases.
Conclusion: RAG is a safe as well as a feasible procedure, providing a satisfactory
postoperative outcome.
27
Video Abstracts
V001: ROBOTIC-ASSISTED RESECTION OF ESOPHAGEAL LEIOMYOMA
Koji Park, MD, Syed Razi, MD, Jordan Sasson, MD, Cliff P Connery, MD,
George J Todd, MD, Scott J Belsley, MD, Faiz Y Bhora, MD St. Luke’s-
Roosevelt Hospital Center
Introduction: Esophageal leiomyoma is a rare benign esophageal tumor, accounting
for <1% of all esophageal tumors. Leiomyomas are generally asymptomatic until
they are >5cm in size. Larger esophageal leiomyomas are typically associated with
symptoms related to mass-effect, most often dysphagia. Recommended treatment
of these larger, symptomatic lesions is surgical excision. Traditionally, leiomyomas
are excised via open thoracotomy. However, minimally invasive techniques via
thoracoscopy have been described recently. We propose that a robotic-assisted
approach is a safe and feasible method of excising large esophageal leiomyomas.
Methods & Procedures: After induction of general endotracheal anesthesia, the
patient was turned in the left lateral decubitus position. An endoscope was easily
passed through the esophagus into the stomach. Upon entry into the chest, the
large esophageal mass was seen adjacent to the azygos vein and superior vena
cava. The da Vinci Robot was then introduced and the mediastinal pleura was
opened with cautery. The thin, overlying muscle layer was divided and the
avascular plane between the esophageal muscularis and the mass was dissected
circumferentially, with great care taken not to violate the mucosa. The mass
was placed in a specimen bag and removed. An air leak test was performed
with the esophagus submerged under saline irrigation. Intraoperaive endoscopy
confirmed no evidence of leak. The esophageal muscle layer and pleura were
closed in order to prevent pseudodiverticulization of the mucosa.
Results: Total operative time was 3 hours and 3 minutes. Blood loss was minimal.
There were no intraoperative or postoperative complications. A postoperative
swallow study demonstrated no evidence of leak. The patient’s chest tube was
removed on the first postoperative day, and the patient was discharged home on
the second postoperative day. Pathology confirmed the presumptive diagnosis of
leiomyoma.
Conclusions: The superior ergonomics and three-dimensional visualization
associated with the da Vinci robot facilitates the safe dissection of a large bulky
tumor from the esophagus, minimizing the risk of injury to adjacent vascular
structures and to the esophageal mass. This case demonstrates the feasibility and
safety of the robotic-assisted resection of large esophageal leiomyomas.
V002: ROBOTIC SINGLE PORT RIGHT HEMICOLECTOMY IN AN OBESE
PATIENT Vincent Obias, MD, Rami Makhoul, MD, Sam Damle, MD, Grace
Montenegro, MD George Washington University
Purpose: To demonstrate a robotic right hemicolectomy in an obese patient,
demonstrate the steps associated with a single port robotic right hemicolectomy,
and provide technical tips on robotic single port surgery
Methods: The patient was placed in supine position. One inch incision made in
skin and fascia. A Covidien SILS port used. Laparoscopic single incision surgery
was done to explore the abdomen and identify structures. The robot was then
docked using a two working arm technique with the robotic arms crossed at
the fascia level. Once the robot was docked, the robotic arm designation on
the console was switched so that the left arm on the screen is now controlled
by the left hand in the console and the right arm on the screen is controlled
by the right hand. We next did a standard right hemicolectomy by ligating the
ileocolic artery, dissecting medial to lateral separating the right and transverse
colon mesentary from the retroperitoneum, mobilized the right colon and
proximal transverse colon, exteriorized the right colon, transecting it, and then
performing an ileocolic anastamosis.
Results: Operative time was 180 minutes. Length of stay was 4 days. No post
operative complications noted. The surgeon noted improved ergonomics, better
tissue manipulation and a greatly improved view due to the high definition 3D
view and the stable camera platform.
Conclusion: Robotic single port surgery is a viable alternative to traditional single
port laparoscopy and has some advantages over laparoscopic single port surgery.
V003: ROBOT-ASSISTED THORACOSCOPIC ESOPHAGECTOMY AND
LYMPHADENECTOMY RJJ Verhage, MD, PC van der Sluis, MD, R van
Hillegersberg, MD PhD University Medical Center Utrecht, the Netherlands
Thoracoscopic esophagectomy was introduced to reduce the morbidity of
conventional open transthoracic esophagectomy. In the University Medical
28
Center Utrecht (The Netherlands) patients with resectable esophageal
cancer undergo robot assisted thoracolaparoscopic esophagectomy. Extensive
experience with this procedure has been gained since 2003.
The presented case concerns a 48 year old male patient with an ultrasound
confirmed T3N1 adenocarcinoma of the distal esophagus. The indicated
procedure for this patient is a robot assisted thoracolaparoscopic esophagectomy
with a 2-field lymphadenectomy. The procedure is marked by three distinct
phases; 1) esophageal mobilization and mediastinal lymphadenectomy by robot
assisted thoracoscopy, 2) gastric mobilization and truncal lymphadenectomy by
conventional laparoscopy, 3) esophageal dissection through cervicotomy and
reconstruction with a gastric conduit.
The presented video focuses on the robot assisted thoracoscopic part of this
procedure showing esophageal mobilization and mediastinal lymphadenectomy.
The DaVinci Si robotic system is used for improved surgical control and vision
within the surgically challenging environment of the thorax and mediastinum.
The application of the robot in this procedure enables a precise and extensive
lymphadenectomy and maximizes chances of oncological clearance.
One camera port and two instrumental ports are placed. The operating surgeon
is assisted by an assisting surgeon through two additional ports, mainly used
for suctioning and application of hemoclips. To enhance vision of the operative
field, single lung ventilation is applied and the esophagus is manipulated with
the use of a penrose drain. Thoracoscopic mobilization of the esophagus
and surrounding tissue is followed by conventional laparoscopy for gastric
mobilization and truncal lymphadenectomy. After laparoscopy, the proximal
esophagus is dissected through a left-sided cervicotomy. The gastric conduit is
formed extracorporally with the use of GIA stapling and is routinely oversewn
to prevent leakage. The procedure is then completed with a handsewn end-to-
side esophagogastrostomy and removal of excess gastric tubing. Postoperative
intake is ensured with a feeding jejunostomy.
Postoperative recovery was uneventful and the patient was discharged from the
hospital ten days after surgery. Forty days later the feeding jejunostomy was
removed in the outpatient clinic after full recovery of oral intake.
V004: ROBOTICS MAY SAVE THE DAY WITH GANGRENOUS
CHOLECYSTITIS: A NOT SO USELESS OPERATION AFTER ALL
Konstantinos M Konstantinidis, MD PhD FACS, Savas C Hiridis, Periklis S
Chrysocheris, Michael K Georgiou, MD ATHENS MEDICAL CENTER
Introduction: Many studies support that conversion performed for minimally
invasive cholecystectomy is a proof of professional responsibility; gangrenous
acute cholecystitis is one of the most important causes of conversion. Robotics
overcome certain limitations of laparoscopic surgery with superior visualization
of the field and dexterous wristed instruments. Robotic cholecystectomy is
considered as a good start for the learning curve of a new robotic surgical team.
Aim: To present our experience with robotic cholecystectomy in difficult cases.
Methods: We present 83 robotic cholecystectomies performed by our team
since September 2006. In 14 of these cases, a challenging advanced gangrenous
state of the gallbladder was managed robotically without complications or any
considerations for conversion.
Results: All patients followed an uneventful recovery including those with the
gangrenous cholecystitis. There were no conversions, neither serious morbidity
and no mortality. Recognition of the critical view during initial dissection was
greatly facilitated by the robot, especially in complicated cases with abundant
adhesions. The operation was not affected by the patient’s BMI.
Conclusions: Robotic cholecystectomy is a safe operation. Robotics may save the
day in difficult cases of distorted anatomy and diffuse inflammation and should be
considered as an alternative to conventional laparoscopy if the system is available.
V005: ROBOTIC DISTAL PANCREATECTOMY: OUR TECHNIQUE.
Konstantinos M Konstantinidis, MD PhD FACS, Savas C Hiridis, MD MSc,
Michael K Georgiou, Perikles S Chrysocheris, MD aFACS Athens Medical Center
Introduction: Tumors of pancreatic tail can be resected laparoscopically with
good results. Robotics may offer a more stable platform for dissection and
mobilization of such tumors especially when the spleen should be preserved.
Aim: We present the technique used by our team for robotic removal of
pancreatic tail masses with or without splenic preservation.
6 TH ANNUAL MIRA CONGRESS May 11-13, 2011
 Methods: A robotically - assisted distal pancreatectomy with splenectomy was
performed in 7 cases. Spleen preservation was performed in 2 cases succesfully.
The da Vinci system greatly facilitated dissection around the pancreatic tail,
mobilization of the stomach and omentum and dissection in the splenic hilum.
The specimens were extracted in an endobag. In 2 cases an extension of the
left lateral incision was made and an extracorporeal division of the pancreas
performed. In the rest of cases, division of the pancreatic tail was performed
endoscopically using an endostapler.
Results: There was no blood loss, nor any need for transfusion, while operation
time was comparable to laparoscopy. The patients had an uneventful recovery and
left the hospital on the 5th postoperative day. A minor leak from the drain was
noticed in two of the patients but gradually subsided with conservative measures.
Conclusions: Robotically-assisted distal pancreatectomy is a valid treatment option
for pancreatic tail tumors especially when preservation of spleen is attempted.
V006: KIDS SAY THE DARNDEST THINGS...AND WHAT THEY EAT IS
PRETTY WEIRD TOO John J Meehan Seattle Children’s Hospital, University
of Washington
Of the nearly 50 diffferent types of robotic procedures we have performed in
children, this one has to be the most unusual...but also the most memorable.
Foreign body ingestion is a common problem amongst toddlers and small
children. The cricopharyngeus is the most narrow region of the GI tract and
any solid objects that pass this region have a high likihood of continuing without
incidence. However, that did not happen in the case we are presenting here. In
fact, we are still surprised that this thing ever made it past the cricopharyngeus.
We offer a video presentation of an unusal application of the da Vinci surgical
robot in a 5 year old child who swallowed a large smooth object that somehow
passed the cricopharyngeus but would not pass the pylorus. Although we will
leave the identity of the object a mystery until the video is seen at the meeting
(an amusing but minor detail to the case itself), the size of the object was the
most striking issue in this case. An endoscopic attempt at retrieval using a
flexible endoscope and basket failed as the object was too big to be brought back
up the esophagus despite numerous efforts (what goes down doesn’t always
come back up). The da Vinci Surgical robot was used to create a gstrotomy
and retrieve the object rock from the stomach, and bring it out through an
abdominal incision. This is an unusal application of the robot but demonstrates
the versatility of this technology. Since a picture is worth a thousand words, and
a movie is probably worth a book, we’ll let the video speak for itself .
V007: ROBOTIC TRACHELECTOMY Vasilis Kapetanakis, MD, Paul M
Magtibay, MD Mayo Clinic, AZ
In recent years there has been a renewed interest in supracervical hysterectomies.
Reported outcomes have shown that up to 24% of women undergoing
supracervical hysterectomy require re-operation secondary to neoplasia, cyclical
bleeding, pelvic pain, dyspareunia, and vaginal discharge. We present a patient
with a history of chronic pelvic pain and multiple abdominal surgeries. She
underwent supracervical hysterectomy several years prior secondary to uterine
leiomyomata. We demonstrate the robotic approach to deep pelvic dissection with
isolation of the ureters and removal of the cervical stump. The robotic system
facilitates careful dissection of the cervix and identification of the ureters which is
essential in order to avoid injury to the surrounding pelvic structures.
V008: A PECULIAR VASCULAR INJURY IN ROBOTIC HYSTERECTOMY
Rhoda Raji, MD, Karim ElSahwi, MD, Masoud Azodi, MD Yale-New Haven
Hospital
Objectives: To present a case of external iliac vein injury during extraction of the
uterus and to demonstrate its management
Methods: A video presentation
Results: This video shows an injury to the right external iliac vein during vaginal
extraction of the uterus after completion of a robotic-assisted hysterectomy. A
uterine manipulator had not been used, and upon trying to reach the 16-week
size fibroid uterus with a single-toothed tenaculum introduced through the
vagina, the right external iliac vein was inadvertently pierced. The robot was
used to disengage the tenaculum and repair the vein. The case was not converted
and the patient suffered no short or long term squeals.
Conclusion: The tips of all instruments should be always kept in full view.
Consistent adherence to the rules of laparoscopy prevents untoward consequences.
www.mirasurgery.org
V009: ROBOTIC HYSTERECTOMY FOR STAGE IV ENDOMETRIOSIS Dan-
Arin Silasi, MD, Taryn Gallo, MD Yale New Haven Health / Bridgeport Hospital
Case presentation: Our patient is a 45 year old female with a long-standing
history of significant pelvic pain. She has a surgical history of three prior
cesarean sections. Preoperative ultrasound shows a complex adnexal mass. Our
video demonstrates our experience with robotic hysterectomy for a Stage IV
endometriosis with a frozen pelvis.
V010: ROBOTIC RADICAL HYSTERECTOMY FOR VAGINAL SARCOMA
Eugene P Toy, MD, Julietta Fiscella, MD University of Rochester
The patient is a 48 year old female who had undergone vaginal resection of an
angiomyofibroblastoma 5 years earlier and now is found to have a recurrent vaginal
tumor noted on workup for abnormal bleeding. Review of her prior pathology
showed a differential of epithelioid leiomyoma in addition to angiofibroblastoma. A
simple vaginal excision had been performed in 2005 with no adjuvant therapy given.
Her current MRI from December 2009 revealed a recurrent mass arising in the right
paravaginal area measuring 5.4 X 4.4 cm. Physical exam confirmed the proximal
right vaginal mass with either mucosal involvement or scarring noted after her prior
resection. No other evidence of adenopathy or uterine pathology was seen.
She subsequently underwent a DaVinci robotic assisted laparoscopic radical
hysterectomy with en bloc resection of the paravaginal mass. The radical
resection was necessary to resect the mass in continuity with the uterus, cervix,
parametria, and upper vagina. Console time was 3 hrs and 50 minutes with
estimated blood loss of 100 ml. The patient was discharged home on post-
operative day one. The intraoperative pathology was reported as an epithelioid
angiosarcoma. Final pathology was revised to malignant mesenchymal neoplasm
arising in the posterior paravaginal sac. Closest margin was within 5 mm, and
she received adjuvant radiation and chemotherapy.
V011: ROBOTIC HYSTERECTOMY: APPROACH TO THE BULKY FIBROID
UTERUS Mona Orady, MD Division of Minimally Invasive Gynecology and
Robotic Surgery, Department of Obstetrics, Gynecology, and Women’s Health,
Henry Ford Health System, Detroit, MI, USA
The benefits of minimally invasive methods of hysterectomy are well described.
Minimally invasive hysterectomy offers patients smaller incisions, decreased blood
loss, decreased length of stay, and a faster recovery and return to normal activities.
Since the FDA approval of the daVinci Surgical System for use in Gynecology in
April 2005, robotic hysterectomy has helped to extend the ability of surgeons to
perform hysterectomy in patients who may not otherwise have been candidates for
a minimally invasive approach, such as in those with extremely large bulky uteri
making traditional laparoscopic hysterectomy difficult.
This is a case of a 39 year old gravida 3 para 3 woman who presented with a
large, bulky fibroid uterus causing menorrhagia, dysmenorrhea, and pelvic pain
symptoms. Childbearing was complete. She had failed medical management in
the past and desired definitive management with hysterectomy. Uterine depth
sounded to 13 cm and on pelvic MRI the uterus measured 15 x 7 x 12 cm. The
largest fibroid was posterior, measured 9cm, and filled the pelvis. The patient
was offered a robotic assisted total laparoscopic hysterectomy of this very large
bulky uterus in order to avoid laparotomy.
This video presentation illustrates the careful and precise dissection made
possible using the assistance of the daVinci robot. The magnified three-
dimensional vision and the precision and dexterity of the robotic instruments
facilitated manipulation of the uterus and dissection of the retroperitoneal
space allowing for efficient and safe removal of this bulky uterus in a minimally
invasive manner. Approach to the side-wall to side-wall uterus is discussed and
techniques for manipulating and removing such a large structure are illustrated.
V012: ROBOTIC APPENDECTOMY DURING GYNECOLOGIC SURGERY:
3 DIFFERENT TECHNIQUES Taryn N Gallo, MD, Dan-Arin Silasi, MD,
Masoud Azodi, MD Yale New Haven Health / Bridgeport Hospital
Background: Appendectomy is a common procedure during gynecologic surgery.
There are numerous indications including endometriosis, pelvic pain, abnormal
appearance, and malignancy.
Objective: To demonstrate three different techniques for appendectomy during
robotic gynecologic surgery. Methods: Three robotic cases are presented focusing
on technique for appendectomy. Conclusion: Robotic appendectomy can be
performed using several methods during gynecologic surgery when indicated.
29
Video Abstracts
V013: ROBOTIC RADICAL PROSTATECTOMY IN GREECE:5-YEAR
EXPERIENCE Nick Pardalidis, Nick Andriopoulos, Aggelos Karamanis, Niki
Giannakou, Eleni Kosmaoglou Athens Medical Centre, Marousi, Greece
Purpose: Radical prostatectomy is the treatment of choice for the management of
organ confined prostate cancer. Minimal invasive treatments as an alternative,
have been refined recently by the addition of the da Vinci robotic technology
which has the potential to improve surgical outcomes and reduce the steep
learning curve associated with conventional laparoscopic radical prostatectomy.
We report our 5-year experience with robotic radical prostatectomy using the
da Vinci robotic system.
Materials & Methods: Since 2006, more than 200 robotic radical prostatectomies
were performed by a single surgical team at Athens Medical Centre (Marousi,
Greece). Preoperative data collection included basic demographics, prostate
specific antigen (PSA), clinical stage and Gleason score. Operative outcomes
included operative time, estimated blood loss and complications. Postoperative
outcomes included hospital stay, pain, catheter time, pathology, PSA, return of
continence and potency.
Results: Average operative time was 168,25 minutes with an estimated mean
blood loss of 135ml. 90% of the patients were discharged home on postoperative
day 1. All patients reported minimal postoperative pain and resumed regular
diet on the first postoperative day. Average catheter time was 6,6 days
(range 5-10). Our potency results demonstrate that surgical skills along with
athermal technique are the key points for the preservation of the neurovascular
bundle. Early continence was observed in 57,5% of the patients, 7 days after
catheter removal. Continence at 1, 3 and 6 months was 82,5%,88% and 95%
respectively. The overall positive margin rate was 15,5%. 95% of the patients
had undetectable postoperative PSA levels (less than 0,1ng/ml) at a median
follow up of 24 months.
Conclusions: Our experience with robotic radical prostatectomy proves that
yhe method is safe and effective, combining the minimal morbidity with good
oncological and functional outcomes.
V014: ROBOTIC-ASSISTED INSERTION OF AN ARTIFICIAL URINARY
SPHINCTER AFTER PELVIC TRAUMA AND URETHRAL DISRUPTION
Jonathan J Melquist, MD, Ruth Ann Miles, MD, Zelik Frischer, MD, Rahuldev
Bhalla, MD Stony Brook University Medical Center
Objective: Implantation of artificial urinary sphincter is an established procedure
for urinary incontinence. We report on a novel robotic technique for the
placement of an artificial urinary sphincter (AUS) in a female patient after major
pelvic trauma and complete urethral disruption.
Patients & Methods: A 53 year-old female presents with urinary incontinence after
a motorcycle crash, which resulted in a pubic symphysis fracture, sacro-iliac
disruption, and urethral disruption. The patient failed multiple other surgical
interventions to treat her Type III SUI. Robotic-assistance was utilized in aiding
placement of an AUS in the face of technically challenging anatomy.
Results: Robotic-assistance was successfully employed for the dissection for an
AUS in this technically challenging patient with previous pelvic trauma and
multiple incontinence surgeries. Total robotic operative time was 2.5 hours.
Estimated blood loss was minimal at 50 mL. The patient was discharged from
the hospital Post-Operative Day 4 with minimal narcotic use and the catheter
was removed on Day 7. The sphincter was activated after 6 weeks. The patient
is currently continent with use of the AUS and went from using 3-4 pads/day to
0-1 pads/day.
Conclusion: To our knowledge this is the first report of robotic-assistance in
placement of an AUS in a female patient. The robotic assistance allowed us to
meticulously dissect the periurethral tissue off the vaginal wall with minimal
morbidity. This was technically feasible and necessary in this otherwise
inoperable patient.
V015: SEQUENTIAL PHOTOSELECTIVE VAPORIZATION OF THE
PROSTATE AND ROBOT-ASSISTED LAPAROSCOPIC BLADDER
DIVERTICULECTOMY Nick Pardalidis, Nick Andriopoulos, Aggelos
Karamanis, Eleni Kosmaoglou Athens Medical Centre
Purpose: Bladder diverticula are herniations of the bladder mucosa through
the bladder musculature. Acquired bladder diverticula are the result of outlet
obstruction caused mostly by benign prostatic enlargement or bladder neck stricture.
30
Open surgery, endoscopic and laparoscopic techniques are surgical options for
the management of bladder diverticuli. We report photoselective vaporization of
the prostate (PVP) and robot-assisted bladder diverticulectomy (RABD) in the
same patient for the management of a large symptomatic bladder diverticulum.
Materials & Methods: A 57 year old patient with bladder outlet obstruction and a
secondary large bladder diverticulum underwent sequential PVP and RABD.
The size of the diverticulum was 8x7x6 cm. PSA was 1,8 ng/dl, prostate volume
30cc, post-void residual 500cc and flow rate was 5 ml/sec. Cystoscopy revealed
obstruction due to lateral prostatic lobes and bladder neck stricture. After
the PVP procedure a 20 Fr open-end urethral catheter was inserted into the
diverticulum via a guide wire, in order to distend it with normal saline infusion.
The distended diverticulum was easily detected and transected at its neck from
the bladder using the da Vinci robotic system. The bladder opening was closed
in two separate layers and was checked for watertight closure by instilling saline
through the urethral catheter.
Results: The total operative time was 145 min. No intraoperative complications
were encountered. The patient was discharged the following day and the catheter
was removed on the fifth postoperative day after cystographic examination.
Flexible cystoscopy revealed no evidence of residual diverticula. The patient had
uneventful recovery and excellent urination after catheter removal.
Conclusions: Sequential PVP and RABD appear to be a safe, effective as well as
minimally invasive alternative procedure for the management of large bladder
diverticulum.
V016: ROBOTIC ASSISTED ANTERIOR EXENTERATION FOR
URETHRAL CANCER Rhoda Raji, MD, Karim Elsahwi, MD, Masoud Azodi
Department of Obstetrics, Gynecology and Reproductive Sciences, Yale-New
Haven Hospital, New Haven, CT, 06520
Objectives: To describe robotic assisted anterior exenteration in a 43 year-old
patient with urethral cancer.
Methods: A video presentation
Results: A 43 year-old woman presents with irritative and obstructive urinary
symptoms, a urethral diverticulum is diagnosed. Diverticulectomy reveals
adenocarcinoma originating in urethral glands. She receives four cycles
of cisplatinum and docetaxel with partial response. PET-CTshows a 4 cm
urethral mass invading the base of the bladder. No metastases are reported.
She undergoes a robotic-assisted anterior exenteration. Urinary diversion
is performed by urology service through a minilaparotomy. Neovaginal
reconstruction performed by plastics service. Post operative course is
complicated by bleeding from the neovagina flap managed by embolization.
Conclusion: The meticulous dissection advantages and minimally invasive virtues
offered by the da Vinci Robot allows it to yield itself favorably in complicated
gynecologic oncology procedures. Exenteration is nonetheless major surgery
warranting close observation in the postoperative period.
V017: ROBOT-ASSISTED LAPAROSCOPIC RADICAL
CYSTOPROSTATECTOMY: TOTALLY INTRACORPOREAL STUDER
NEOBLADDER Nick Pardalidis, Nick Andriopoulos, Niki Giannakou, Evagelia
Karagianni, Eleni Kosmaoglou Athens Medical Center, Maroussi, Athens,
Greece
Objectives: To describe da Vinci laparoscopic radical cystoprostatectomy and
intracorporeal ileal Studer neobladder formation.
Materials: We performed robot-assisted laparoscopic radical
cystoprostatectomies and intracorporeal construction of orthotopic Studer
neobladder in 5 patients.
Summary of results: The mean operative time was 7.5 hours. The mean blood loss
was 140ml. There were no intraoperative or postoperative complications and
the patients’ hospital stay was 5 days. Good oncological and functional results
were encountered at early follow up.
Conclusion: Our initial experience with robotic-assisted laparoscopic radical
cystoprostatectomy appears to be favorable with acceptable operative, pathologic
and short-term clinical outcomes.
6 TH ANNUAL MIRA CONGRESS May 11-13, 2011
 V018: ROBOTIC THYMECTOMY IN A CHILD WITH MYESTHENIA
GRAVIS Jacob Stephenson, MD, John J Meehan, MD FACS, Daniel Ledbetter,
MD Seattle Children’s Hospital
A child with global weakness was diagnosed with myesthenia gravis. Medical
therapy was fairly ineffective and the patient underwent a robotic thymectomy
through the left chest. We present this procedure in a video presentation and
demonstrate the utility of the new 8.5 mm 3-D HD scope used for this procedure.
V019: ROBOTIC MICROSURGICAL NERVE GRAFTING FOR
SYMPATHECTOMY REVERSAL: TECHNIQUE AND FEASIBILITY FOR
FIRST HUMAN CASE M. Jawad Latif, MD, Koji Park, MD, Syed S Razi, MD,
Faiz Bhora, MD, George Todd, MD, Noel Perin, MD, Cliff Connery, MD, Scott
J Belsley, MD St. Luke’s Roosevelt Hospital Center, Columbia University
Objective: Compensatory sweating (CS) is a well established side effect in
patients undergoing thoracoscopic sympathectomy for Primary Hyperhydrosis.
There are no effective medical treatment options for debilitating CS. Our
objective was to restore anatomic and possible physiological function using
microsurgical techniques with autologous nerve grafts. This study follows our
success on a porcine model developed in our laboratory where sympathetic
chain reconstruction was achieved in a minimally invasive fashion with standard
neurosurgical principals and microsurgery using the da Vinci robot. We describe
this novel application of the da Vinci robot in a human patient suffering from a
decline in quality of life and severe CS after thoracoscopic sympathectomy.
Methods & Procedures: A first generation da Vinci system was used for this
operation. Reversal was performed on both sides with the patient in lateral
decubitus position requiring undocking the robot and flipping the patient mid-
procedure. Single lung ventilation was achieved via double lumen tube. Standard
triangulated port placement for three robotic arms was performed under direct
visualization. An additional fourth working port was placed between the camera
and right robotic arm port. Previous areas of sympathetic interruption were
identified. By using da Vinci’s magnified view, the sympathetic chain and intact
ganglia were carefully dissected between these segments. Two size appropriate
intercostal nerve grafts were harvested from third and fourth intercostal rib
spaces respectively and used as direct grafts and in one case as an interposition
graft to restore continuity of sympathetic chain. Tension free nerve anastomoses
were performed between identifiable isolated gnglia via 8-0 Prolene interrupted
sutures which were further supported by pleural buttress as necessary.
Preliminary Results: The operation was successfully accomplished robotically
without any need of conversion to open surgery in about 9 hours. Right sided
operation took approximately six hours while the contralateral side was
considerably faster. The patient tolerated intermittent thoracic insufflation and
single lung ventilation. The patient was hyperthermic with manipulation of
the ganglia but remained hemodynamically stable with minimal blood loss and
an uncomplicated post operative course. Patient was discharged home on post
operative day 1. On short term follow up, patient did not have any evidence of
Horner’s syndrome. Long term results of functional outcome are pending.
Conclusions/Expectations: This novel application of da Vinci robot for thoracic
sympathetic chain reconstruction is technically feasible in human subjects. The
3-D magnification and manual dexterity of robot allows for nerve microsurgery
in a minimally invasive fashion as compared to standard thoracotomy. Although
functional outcome for autonomic reconstruction is unknown, it is expected to
yield comparable results to an open operation. Further investigation is ongoing.
www.mirasurgery.org
V020: ROBOTIC-ASSISTED THORACOSCOPIC REPAIR OF A
DIAPHRAGMATIC HERNIA WITH LIVER HERNIATION AND
ENDOMETRIOSIS CAUSING RECURRENT CATAMENIAL
PNEUMOTHORAX Gary S Schwartz, MD, Koji Park, MD, Syed Razi, MD,
Scott J Belsley, MD, Faiz Y Bhora, MD, Cliff P Connery, MD St. Luke’s-
Roosevelt Hospital Center
Introduction: We describe a case of recurrent catamenial pneumothorax
associated with a diaphragmatic hernia with liver herniation and endometriosis.
Primary repair with a human acellular dermis overlay was accomplished via
robotic-assisted thoracoscopy.
Methods: One of multiple small diaphragmatic nodules was excised with
electrocautery. The diaphragm was mobilized circumferentially from the liver,
which was herniating through the diaphragmatic defect. Primary repair of the
hernia was accomplished with interrupted 0-Ethibond sutures. Several attenuated
areas of the diaphgragm were noted. The decision was made to overlay with
diaphragm in order to induce fibrosis and seal any potential fenestrations. A
piece of human acellular dermis was sutured circumferentially with interrupted
0-Ethibond sutures. A completion pleurectomy was then performed.
Results: There were no intraoperative or postoperative complications. The total
operative time was 4:28. The patient’s chest tubes were removed and she was
discharged home on the third postoperative day. Histological evaluation of the
diaphragmatic nodule revealed mesothelial proliferation with no evidence of
endometriosis.
Conclusions: Primary repair of a diaphragmatic hernia with a human acellular
dermis overlay via robotic assisted thoracoscopy is safe and feasible.
Suturing was facilitated by the superior ergonomics of the robotic approach.
Circumferentially securing the overlay patch would have been exceedingly
difficult through standard thoracoscopy, given the difficult working angles and
limited range of motion within the rigid confines of the chest wall. The robotic
approach can help overcome the formidable ergonomic challenges associated
with performing complex thoracoscopic tasks.
V021: NOT A MATTER OF SIZE Vasiliki Chatzirafail, MD, Michael Litos, MD
PhD MRCOG, Antigoni IssarI, MD Euroclinic, Athens, Greece
It is often thought that large size is the only limiting factor for endoscopic
myomectomy, and that small fibroids can be easily excised laparoscopically or
robotically. We present a video indicating that small size can be a draw back and
that location can be equally important, if not more so.
A 44 years old, para 2, woman presented with persistent pelvic pain and
dyspareunia. Ultrasonographic examination revealed a 6cm fibroid located
to the left of the cervix. Hysterectomy was discussed and declined, so it was
decided to have a robotic myomectomy. At the operation the fibroid was not
visible even after opening the broad ligament and dissecting the ureter and the
uterine vessels and exposing the lateral part of the uterus. Not being possible
to indetifiy the fibroid, stripping the left side of the uterus and cervix was
innevitable and the operation was converted to robotic total hysterectomy. The
operation was completed uneventfully and the fibroid was found attached to the
lower end of the cervix.
Robotic assistance provides good access, stereoscopic view and precise
maneuvers that facilitate excision of fibroids in difficult positions or of big size,
as suggested by our experience that we present elsewhere. In this particular case
it was not possible to perform a myomectomy and this was not a matter of size.
V022: ROBOTIC SURGERY FOR ENDOMETRIOSIS UTILIZING THE 5MM
DAVINCI SYSTEM Taryn n Gallo, MD, Masoud Azodi, MD Yale New Haven
Health / Bridgeport Hospital
Objective: To present our experience utilizing the 5mm pediatric instruments
with robotic surgery for significant endometriosis.
Method: Case presentation utilizing the 5mm pediatric instruments for a 23 year
old patient with bilateral endometriomas and significant adhesive disease.
Conclusion: Although there is no bipolar instruments or hot scissors, robotic
surgery for gynecologic indications can be performed utilizing the 5mm system.
The benefits include improved cosmesis with smaller incisions and decreased
risk for incisional hernia.
31
Poster List
P001 ROBOTICS ENABLES A MINIMALLY INVASIVE APPROACH TO RIGHT SIDED EPIPHRENIC DIVERTICULUM Barbara Tempesta, CRNP, Marc Margolus,
MD, Eric Strother, CSA, Farid Gharagozloo, MD, Washington Institute Of Thoracic And Cardiovascular Surgery; The George Washington University Medical Center
P002 ROBOTIC APPROACH TO A LEFT SIDED EPIPHRENIC DIVERTICULUM Farid Gharagozloo, Marc Margolis, MD, Eric Strother, CSA, Barbara
Tempesta, CRNP, Washington Institute Of Thoracic And Cardiovascular Surgery; The George Washington University Medical Center
P003 ROBOTIC LAPAROSCOPIC GASTROESOPHAGEAL VALVULOPLASTY FOR THE TREATMENT OF GASTROESOPHAGEAL REFLUX DISEASE
Farid Gharagozloo, MD, Eric q Strother, CSA, Marc Margolis, MD, Barbara Tempesta, CRNP, Washington Institute Of Thoracic And Cardiovascular Surgery; The
George Washington University Medical Center
P004 ROBOT-ASSISTED THORACOSCOPIC RIGHT UPPER LOBECTOMY FOR EARLY STAGE LUNG CANCER - A VIDEO PRESENTATION OF ROBOT
POSITIONING AND OPERATIVE TECHNIQUE Farid Gharagozloo, Marc Margolis, MD, Eric Strother, CSA, Barbara Tempesta, CRNP, Washington Institute
Of Thoracic And Cardiovascular Surgery; The George Washington University Medical Center
P005 DECREASED POST-OPERATIVE PAIN WITH A NOVEL PORT CLOSURE IN THORACIC ROBOTIC SURGERY Eric Strother, CSA, Marc Margolis,
MD, Barbara Tempesta, CRNP, Farid Gharagozloo, MD, Washington Institute Of Thoracic And Cardiovascular Surgery; The George Washington University
Medical Center
P006 ROBOTIC SEGMENTECTOMY OF EARLY STAGE LUNG CANCER Farid Gharagozloo, Marc Margolis, MD, Eric Strother, CSA, Barbara Tempesta,
CRNP, Washington Institute Of Thoracic And Cardiovascular Surgery; The George Washington University Medical Center
P007 ROBOTIC SURAL NERVE GRAFT FOR REVERSAL OF THORACIC SYMPATHECTOMY Farid Gharagozloo, Marc Margolis, MD, Eric Strother, CSA,
Barbara Tempesta, CRNP, Washington Institute Of Thoracic And Cardiovascular Surgery; The George Washington University Medical Center
P008 ROBOTIC ASSISTED THORACOSCOPIC RESECTION OF BRONCHOGENIC CYSTS Farid Gharagozloo, MD, Barbara Tempesta, CRNP, Eric Strother,
CSA, Marc Margolis, MD, Washington Institute Of Thoracic And Cardiovascular Surgery; The George Washington University Medical Center
P009 ROBOTIC RELIEF TO THE MEDIAN ARCUATE SYNDROME Farid Gharagozloo, MD, Marc Margolis, MD, Eric Strother, CSA, Barbara Tempesta,
CRNP, Washington Institute Of Thoracic And Cardiovascular Surgery; The George Washington University Medical Center
P010 SUBPLEURAL CATHETER PLACEMENT FOR POST-OPERATIVE PAIN - TECHNIQUE AND INTERMEDIATE TERM RESULTS Barbara Tempesta,
CRNP, Marc Margolis, MD, Eric Strother, CSA, Farid Gharagozloo, MD, Washington Institute Of Thoracic And Cardiovascular Surgery; The George Washington
University Medical Center
P011 PROLONGED OPERATIVE TIME IN ROBOTIC TOTALLY ENDOSCOPIC TOTALLY ENDOSCOPIC COR ONARY BYPASS SURGERY – IS IT AN
ISSUE? Dominik Wiedemann, Nikolaos Bonaros, Thomas Schachner, Felix Weidinger, Eric Lehr, Mark Vesely, Guy Friedrich, Johannes Bonatti, 1 University
Clinic of Cardiac Surgery, Innsbruck Medical University, Austria 2 Division of Cardiac Surgery, Department of Surgery, University of Maryland, USA 3 Division of
Cardiology, University of Maryland, USA 4 Department of Cardiology, Innsbruck M
P012 EARLY AND MIDTERM RESULTS OF TOTALLY ENDOSCOPIC CORONARY ARTERY BYPASS GRAFTING ON BEATING HEART Changqing Gao,
MD, PLA General Hospital
P013 ROBOTIC TOTALLY ENDOSCOPIC CORONARY ARTERY BYPASS GRAFTING FOR SPONTANEOUS CORONARY ARTERY DISSECTION Brody
Wehman, MD, Eric Lehr, MD PhD, Ratnakar Mukherjee, MD, Alina Grigore, MD, Bartley Griffith, MD, Johannes Bonatti, MD, University of Maryland Medical Center
P014 ROBOTIC APPROACH TO GIANT HIATAL HERNIAS WITH PRIMARY REPAIR OF THE DIAPHRAGMATIC HERNIA Sigrid Bairdain, MD, Marc
Margolis, MD, Barbara Tempesta, CRNP, Eric Strother, CSA, Farid Gharagozloo, MD, Washington Institute of Thoracic and Cardiovascular Surgery; The George
Washington University Medical Center
P015 SHORT-TERM ANGIOGRAPHIC RESULTS OF ROBOTICALLY ASSISTED CORONARY ANASTOMOSIS USING CONVENTIONAL AND CT-
ANGIOGRAPHY Nikolaos Bonaros, MD, Felix Weidinger, MD, Benedikt Hofauer, MD, Gudrun Feuchtner, MD, Fabian Plank, Guy Friedrich, MD, Eric Lehr,
MD, Johannes Bonatti, MD, Thomas Schachner, Md, Department iof Cardiac Surgery, Innsbruck Medical University
P016 CAUSES AND CONSEQUENCES OF POSTOPERATIVE ATRIAL FIBRILLATION IN TOTALLY ENDOSCOPIC CORONARY BYPASS SURGERY Felix
Weidinger, MD, Thomas Schachner, MD, Nikolaos Bonaros, MD, Benedikt Hofauer, Eric J Lehr, MD, Mark Vesely, MD, David Zimrin, MD, Johannes O Bonatti,
MD, Innsbruck Medical University, Department of Cardiac Surgery; University of Maryland Medical Center, Division of Cardiac Surgery
P017 A COMPARATIVE STUDY ON ROBOTIC VERSUS OPEN RIGHT HEMICOLECTOMY FOR CANCER F. Luca, MD, M. Valvo, MD, S. Cenciarelli, MD,
T. Leal Ghezzi, MD, M. Zuccaro, MD, S. Pozzi, MD, R. Biffi, MD, Division of Abdomino-Pelvic Surgery, European Institute of Oncology; Milan, Italy
P018 THE LEARNING CURVE IN RECTAL RESECTION: IS IT FASTER IN ROBOTICS THAN IN LAPAROSCOPY? Olivia Sgarbura, MD PhD, Serban Vasile,
MD, Mihai Eftimie, MD, Irinel Popescu, MD PhD FACS, Fundeni Institute of Digestive Diseases and Liver Transplantation, Bucharest, Romania; University of
Medicine and Pharmacy, Bucharest, Romania
P019 ROBOTIC SURGICAL REMOVAL FOR RECURRENT PELVIC TUMOR AFTER COLON CANCER RESECTION Sorin Paun, PhD, Roxana Ganescu,
MD, I Negoi, MD, Mihaela Burtea, MD, M Beuran, PhD, Emergency Hospital – Bucharest, Romania
P020 ROBOTIC VERSUS LAPAROSCOPIC COLON AND RECTAL SURGERY: EARLY COMPARISONS. Grace Montenegro, MD, Rami Makhoul, MD,
Vincent Obias, MD, George Washington University
P021 LESSONS LEARNT FROM INTRODUCTION OF ROBOTIC COLORECTAL SURGERY IN A SPANISH UNIVERSITY HOSPITAL Elena Ortiz-Oshiro,
MD PhD, Angel Ramos Carrasco, MD PhD, Cristina Pardo Martinez, MD PhD, Iris Sanchez Egido, PhD, Jaime González Taranco, PhD, Jesus Alvarez Fernández-
Represa, MD PhD, Hospital Clinico San Carlos - Universidad Complutense de Madrid
P022 ROBOTIC COLECTOMIES: A SERIES OF 122 CASES Francesca Bazzocchi, MD, Domenico Garcea, MD, Andrea Avanzolini, MD, Barbara Perenze, MD,
Morgagni-Pierantoni Hospital - Forlì -Italy
P023 RE-LEARNING CURVE IN ROBOTIC COLORECTAL SURGERY WITH A NEW DA VINCI SI HD G Spinoglio, MD, R Quarati, MD, F Priora, MD, LM
Lenti, PHD, F Ravazzoni, PHD, V Maglione, MD, Division of Oncologic General Surgery, ASO “SS Antonio e Biagio e Cesare Arrigo”, Alessandria , Italy
P024 COMPARISON OF ROBOTICALLY PERFORMED AND TRADITIONAL LAPAROSCOPIC COLORECTAL SURGERY. HC Pappis, MD PhD FACS, N
Pararas, MD PhD, D Kotsakou, MD, ’Hygeia’ Hospital, Athens, Greece
P025 ROBOT IN TREATING WELL-SELECTED LEFT-SIDED PANCREATIC CANCER- ROBOTIC ANTERIOR RAMPS Chang Moo Kang, Yonsei University
College of Medicine
32 6 TH ANNUAL MIRA CONGRESS May 11-13, 2011
 P026 TRANSHIATAL VERSUS THORACOSCOPIC ROBOTIC ESOPHAGEAL DISSECTION Carlos Loureiro González, Ismael Díez del Val, title, Inmaculada
Cruz González, Saioa Leturio Fernández, Sandra Ruiz Carballo, José Esteban Bilbao Axpe, José Ramón Cotano Urrutikoetxea, Jaime Jesús Méndez Martín,
Gastroesophageal Surgery Unit, Hospital Basurto, Bilbao
P027 AN INTERNATIONAL SURVEY TO EXAMINE ATTITUDES TOWARDS ROBOTIC SURGERY Sheraz R Markar, MRCS MA MBBChir, Ivana Kolic,
MBBS, Alan P Karthikesalingam, MRCS MA MBBChir, Oliver J Wagner, MD, Monika E Hagen, MD, University College London Hospital
P028 ROBOTIC HELLER MYOTOMY: LEARNING CURVE, ADVANTAGES, AND LIMITATIONS Eric C Nelson, MD, Mohamed R Ali, MD, William Smith,
BS, Tamas J Vidovszky, MD, University of California, Davis Medical Center, Sacramento, CA
P029 INITIAL EXPERIENCES OF ROBOT-ASSISTED POSTERIOR RETROPERITONEOSCOPIC ADRENALECTOMY (PRA); SINGLE PORT ACCESS
Sang-Wook Kang, MD, Haeng Rang Ryu, MD, Jong Ju Jeong, MD, Woong Youn Chung, MD, Department of Surgery, Yonsei University College of Medicine
P030 ADVANTAGES OF ROBOTIC GASTRECTOMY IN EXTRAPERIGASTRIC LYMPHADENECTOMY COMPARED TO LAPAROSCOPIC
GASTRECTOMY Kazutaka Obama, MD PhD, Woo Jin Hyung, MD PhD, Yanghee Woo, MD, Kyung Ho Pak, MD, Hyoung-Il Kim, MD PhD, Sung Hoon Noh,
MD PhD, Department of Surgery, Yonsei University College of Medicine
P031 ROBOTIC REDO FOR FAILED LAPAROSCOPIC NISSEN FUNDOPLICATION Ismael Díez del Val, Carlos Loureiro González, Sandra Ruiz Carballo,
Saioa Leturio Fernández, Inmaculada Cruz González, José Esteban Bilbao Axpe, Jaime Jesús Méndez Martín, Ángel Gómez Palacios, Gastroesophageal Surgery
Unit, Hospital de Basurto, Bilbao, Spain
P032 TOTALLY ROBOTIC SUBTOTAL GASTRECTOMY FOR CANCER Carlos Loureiro González, Ismael Díez del Val, Inmaculada Cruz González, Saioa
Leturio Fernández, Sandra Ruiz Carballo, José Esteban Bilbao Axpe, Jaime Jesús Méndez Martín, Gastroesophageal Surgery Unit, Hospital de Basurto, Bilbao
P033 FROM LAPAROSCOPIC TO ROBOTIC GASTROESOPHAGEAL SURGERY Ismael Díez del Val, Carlos Loureiro González, Sandra Ruiz Carballo, Saioa
Leturio Fernández, Inmaculada Cruz González, José Esteban Bilbao Axpe, Jaime Jesús Méndez Martín, Ángel Gómez Palacios, Gastroesophageal Surgery Unit,
Hospital de Basurto, Bilbao
P034 ROBOT-ASSISTED TRANSHIATAL ESOPHAGECTOMY Carlos Loureiro González, Ismael Díez del Val, José Esteban Bilbao Axpe, José Ramón Cotano
Urrutikoetxea, Jaime Jesús Méndez Martín, Gastroesophageal Surgery unit, Hospital de Basurto, Bilbao
P035 ROBOT-ASSISTED THYROIDECTOMY BY TRANSAXILLARY APPROACH Nicolae Constantea, Profesor PhD MD, Dan Axente, MD, 5th Surgical
Clinic, Cluj-Napoca County Hospital, Romania
P036 FEASIBILITY AND SAFETY OF ROBOT ASSISTED-ENDOSCOPIC THYROIDECTOMY-SYSTEMATIC REVIEW Eugenia Yiannakopoulou, MD
Msc PhD, Nikolaos Nikiteas, MD PhD, Christos Tsigris, MD PhD, Faculty of Health and Caring Professions Technological Educational Institute of Athens, 2nd
Department of Propedeutic Surgery School of Medinice NKUA, 1st Department of Surgery School of Medicine NKUA
P037 FEASIBILITY AND SAFETY OF ROBOT ASSISTED-ADRENALECTOMY -SYSTEMATIC REVIEW Eugenia Yiannakopoulou, MD Msc PhD, Nikolaos
Nikiteas, MD PhD, Christos Tsigris, MD PhD, Faculty of Health and Caring Professions Technological Educational Institute of Athens, 2nd Department of
Propedeutic Surgery School of Medinice NKUA, 1st Department of Surgery School of Medicine NKUA
P038 A PROSPECTIVE COMPARISON OF THE VOICE QUALITY AFTER ROBOTIC VERSUS CONVENTIONAL OPEN THYROIDECTOMY FOR THE
PAPILLARY THYROID CANCER 2Jong Ho Yoon, 3Chi Young Lim, 1Kyu Hyung Kim, 1Jae Hyun Park, 1Sohee Lee, 1Haeng Rang Ryu, 1Sang-Wook Kang, 1Jong
Ju Jeong, 1Kee-Hyun Nam, 1Woong Youn Chung, 1Cheong Soo Park, 1Yonsei University College of Medicine,2Asan Medical Center, University of Ulsan College
of Medicine, 3National Health Insurance Corporation Ilsan Hospital
P039 INTRAOPERATIVE NEUROMONITORING OF THE EXTERNAL BRANCH OF THE SUPERIOR LARYNGEAL NERVE DURING ROBOTIC
THYROID SURGERY Su-jin Kim, Kyu Eun Lee, Mi Ra Kwon, Kwan Yoon, Hyuk Jae Choi, Jun Young Choi, Yeo-Kyu Youn, Haeundae Paik Hospital, Seoul
National University Hospital, Korea
P040 ROBOTIC SURGERY FOR MORBID OBESITY: ROUX-EN-Y GASTRIC BYPASS, GASTRIC BANDING, SLEEVE GASTRECTOMY Christina
Delimpalta, Archontis Zampogiannis, NATIONAL AND CAPODISTREAN UNIVERSITY OF ATHENS, MEDICAL SCHOOL and 1st SURGICAL CLINIC,
LAIKON HOSPITAL, ATHENS, GREECE
P041 ENDOSCOPIC AND ROBOTIC THYROID SURGERY WITH LATERAL NECK DISSECTION FOR PAPILLARY THYROID CARCINOMA USING A
BILATERAL AXILLO-BREAST APPROACH June Young Choi, MD, Kyu Eun Lee, MD PhD, Yeo-Kyu Youn, MD PhD, Seoul National University Hospital
P042 ROBOTIC APPROACH FOR ABDOMINAL HERNIAS – A ROMANIAN EXPERIENCE Sorin Paun, PhD, Roxana Ganescu, MD, M Beuran, PhD, C
Turculet, PhD, F Iordache, PhD, I Negoi, MD, D Surdeanu, MD, Emergency Hospital – Bucharest, Romania
P043 ROBOTIC APPROACH FOR HYDATID HEPATIC CYSTS Sorin Paun, PhD, Roxana Ganescu, MD, I Negoi, MD, Mihaela Burtea, MD, B Gaspar, PhD, M
Beuran, PhD, Emergency Hospital – Bucharest, Romania
P044 ROBOTIC ADRENALECTOMY FOR BENIGN AND MALIGNANT PATHOLOGIES Archontis Zampogiannis, Christina Delimpalta, NATIONAL AND
CAPODISTREAN UNIVERSITY OF ATHENS, MEDICAL SCHOOL and 1st SURGICAL CLINIC, LAIKON HOSPITAL, ATHENS, GREECE
P045 GIST DUODENAL RESECTION AND RECONSTRUCTION IS A FEASIBLE ROBOTIC PROCEDURE T . P Singh, MD, Eyad Wohaibi, MD, James
Massullo, MD, Department of Surgery Albany Medical Center
P046 COMPARISON OF SUTURING TASKS USING THE DA VINCI SINGLE-SITE INSTRUMENTS SYSTEM AND LAPAROSCOPIC SINGLE SITE
INSTUMENTS Tamas J Vidovszky, MD, Bernadette Guiroy, MD, Dan Eisenberg, MD, James Lau, MD, Homero Rivas, MD, University of California, Davis
Medical Center, Sacramento, CA; Salinas Memorial Hospital, Salinas, CA; Stanford School of Medicine, Palo Alto, CA
P047 COMPARISON OF PERIOPERATIVE OUTCOMES BETWEEN HAND-ASSISTED LAPAROSCOPIC WHIPPLE’S OPERATION AND ROBOT-
ASSISTED LAPAROSCOPIC WHIPPLE’S OPERATION Eric C.H. Lai, MBChB MRCSEd FRACS, Chung Ngai Tang, MBBS FRCS, George P.C. Yang, MBBS
MRCSEd FRACS, Oliver C.Y. Chan, MBChB MRCSEd FRCS, Michael K.W. Li, MBBS FRCS, Department of Surgery, Pamela Youde Nethersole Eastern Hospital,
Chai Wan, Hong Kong SAR, China
P048 REVISION OF NISSEN FUNDOPLICATION TO ROUX-EN-Y GASTRIC BYPASS WITH THE ROBOTIC SYSTEM DA VINCI. HC Pappis, MD PhD
FACS, N Pararas, MD PhD, D Kotsakou, MD, ’Hygeia’ Hospital, Athens, Greece
P049 ROBOTIC VERSUS LAPAROSCOPIC ROUX-EN-Y GASTRIC BYPASS: META-ANALYSIS Sheraz R Markar, MRCSEng MAcantab, Alan P Karthikesalingam,
MRCSEng MACantab, Sri Thurumathy, MBBS, James Kinross, MRCSEng PhD, Paul Ziprin, FRCS PhD, Academic Surgical Unit, St Mary’s Hospital, Imperial College, UK

www.mirasurgery.org 33
Poster List
P050 ROBOT-ASSISTED CHOLECYSTECTOMY AS A BRIDGE TO ADVANCED ROBOTIC PROCEDURES HC Pappis, MD PhD FACS, N Pararas, MD PhD,
D Kotsakou, ’Hygeia’ Hospital, Athens, Greece
P051 DYSFUNCTION OF THE DA VINCI SURGICAL SYSTEM DURING 260 VARIOUS ROBOTIC PROCEDURES. Francois Pugin, MD, Bucher Pascal, MD,
Buchs Nicolas, MD, Hagen Monika, MD, Morel Philippe, MD, University Hospitals Geneva, Switerland
P052 ROBOTIC-ASSISTED LAPAROSCOPIC TREATMENT OF LIVER CYSTS Daniel Langer, Miroslav Ryska, Jiri Pudil, Eva Laszikova, Surgery Department,
2nd Faculty of Medicine, Charles University and Central Military Hospital Prague, Czech Republic
P053 TRANSVAGINAL NATURAL ORIFICE TRANSLUMINAL ENDOSCOPIC SURGERY (NOTES)- AN OVERVIEW Christina Delimpalta, Archontis
Zampogiannis, National and Capodistrean University of Athens Medical School and 1st Surgical Clinic, Laikon Hospital, Athens, Greece
P054 NOVEL SLIP AND TACTILE SENSOR SYSTEM ON A MIOGRIPPER Luis Gerardo Sanchez Stone, MSc, Abel Ronquillo, MSc, UPAEP, Ergosolar, LAAR
P055 IN SILICO EXPERIMENTAL MODEL OF AN ASSEMBLING RECONFIGURABLE MODULAR MICRO-ROBOT FOR NOTES SURGERY Apollon
Zygomalas, MD MSc, Konstantinos Giokas, MSc, Dimitrios Koutsouris, Prof, University of Patras, School of medicine, Postgraduate Course in Medical Informatics
P056 SOFIE, A ROBOTIC SYSTEM FOR MINIMALLY INVASIVE SURGERY Linda Van den Bedem, dr ir, Ron Hendrix, ir, Gerrit Naus, dr ir, Ruud Van
der Aalst, ir, Nick Rosielle, dr ir, Henk Nijmeijer, prof dr, Jos Maessen, prof dr, Ivo Broeders, prof dr, Maarten Steinbuch, prof dr ir, Eindhoven University of
Technology, the Netherlands, Academic Hospital Maastricht, the Netherlands, Meander Medical Center Amersfoort, the Netherlands
P057 ROBOTICALLY ASSISTED UKA IS MORE ACCURATE THAN MANUALLY INSTRUMENTED UKA Thomas M Coon, MD, Matthew D Driscoll, MD,
Sharon Horowitz, BS, Michael A Conditt, PhD, St Helena’s Hospital, Scott and White Memorial Hospital, MAKO Surgical Corp
P058 SLEEVE GASTRECTOMY FOR MORBID OBESITY WITH THE USE OF THE DA VINCI SURGICAL SYSTEM. A. ALEXANDROU, IOANNIS
PAPANIKOLAOU, D. DIAMANTIS, N. DIMITRIOU, N. MPASIOS, J. GRINIATSOS, A. GIANNOPOULOS, THEODOROS DIAMANTIS, 1st Department of
Surgery of the University of Athens, Laiko Athens General Hospital, 17 Agiou Thoma St, 11527, Athens, Greece.
P059 CAN TOTALLY ROBOTIC LAPAROSCOPIC GASTRIC BYPASS FOR MORBID OBESITY PRECISELY DUPLICATE ANY TRADITIONAL
LAPAROSCOPIC TECHNIQUE? A. ALEXANDROU, IOANNIS PAPANIKOLAOU, D. DIAMANTIS, N. DIMITRIOU, N. MPASIOS, J. GRINIATSOS, A.
GIANNOPOULOS, THEODOROS DIAMANTIS, From the 1st Department of Surgery of the University of Athens, Laiko Athens General Hospital, 17 Agiou
Thoma St, 11527, Athens, Greece.
P060 REMOTE TELE SURGERY : HELP OF LOSSY VIDEO COMPRESSION FOR THE FUTUR Manuela PEREZ, MD, Nedia NOURI, Jean-Marie
MOUREAUX, Denis ABRAHAM, Michel DUFAUT, Jaques HUBERT, PhD, Centre de Recherche en Automatique de Nancy, Nancy-Université, CNRS 2, avenue
de la forêt de Haye, 54516 Vandœuvre-lès-Nancy, France 2 Centre de Recherche en Automatique de Nancy, Nancy-Université, CNRS Faculté des Sciences, BP
70239, 54506 Vandœuvre-lè
P061 RESULTS OF A PROFICIENCY-BASED CURRICULUM WITH THE VIRTUAL REALITY ROBOTIC SURGERY SIMULATOR: DV-TRAINER.
PERRENOT Cyril, PEREZ Manuela, MD, TRAN Nguyen, MD, HUBERT Jacques, MD, CHU de Nancy
P062 ACCURACY OF ROBOTICALLY ASSISTED ACETABULAR CUP IMPLANTATION Douglas E Padgett, MD, Lawrence D Dorr, MD, Miranda L
Jamieson, MS, Michael A Conditt, PhD, Hospital for Special Surgery, Good Samaritan Hospital, MAKO Surgical Corp
P063 ACCURACY OF UKA COMPONENT PLACEMENT WITH DYNAMICALLY REFERENCED TACTILE ROBOTICS Nicholas D Dunbar, MS, Martin W
Roche, MD, Brian H Park, BS, Sharon Horowitz, BS, Michael A Conditt, PhD, Scott A Banks, PhD, Holy Cross Hospital, University of Florida, MAKO Surgical Corp
P064 HAPTIC ROBOTICS FOR MINIMALLY INVASIVE, MODULAR KNEE ARTHROPLASTY Scott A Banks, PhD, Rony Abovitz, MS, Arthur Quaid, PhD,
Jason K Otto, PhD, Michael A Conditt, PhD, University of Florida, MAKO Surgical Corp
P065 THE LEARNING CURVE OF ROBOTIC-ASSISTED UKA Riyaz Jinnah, MD, Sharon Horowitz, BS, Tamas Erdos, BS, Michael A Conditt, PhD, Wake
Forest University, MAKO Surgical Corp
P066 ROBOTIC SLEEVE GASTRECTOMY. AN INTERMEDIATE APPROACH TO UNDERGO TOTALLY ROBOTIC GASTRIC BY-PASS. RAMON
VILALLONGA, PhD, JOSE MANUEL FORT, PhD, MIRIAM ZAMORA, MONTSERRAT CHINCHILLA, NURIA ROS, OSCAR GONZALEZ, PhD, MANEL
ARMENGOL CARRASCO, PhD, Universitary Hospital Vall d’Hebron. Barcelona.
P067 DEVELOPMENT OF AN AUTOMATED REAL-TIME MR GUIDED ROBOTIC SYSTEM FOR HIGH PRECISION DIAGNOSTIC AND THERAPEUTIC
INTERVENTIONS IN BREAST. Mehran Anvari, MB BS PhD FRCSC FACS, Julian Dobranowski, MD FRCPC, Kevin J Randall, PhD, Peter Lovrics, MD FRCSC,
N Konyer, BSc, T Fielding, MSc, K Morency, MSc, Centre for Surgical Invention and Innovation; MacDonald, Dettwiler and Associates
P068 3D VISUALIZATION AND TRAJECTORY PLANNING SYSTEM FOR REAL TIME INTERVENTION Mehran Anvari, MB BS PhD FRCSC FACS, Bart
Verzijlenberg, MSc, Julian Dobranowski, MD FRCPC, Kevin Randall, PhD, Centre for Surgical Invention and Innovation; MacDonald, Dettwiler and Associates
P069 MINIMIZING HEPATIC TRAUMA WITH A NOVEL LIVER RETRACTION METHOD DURING ROBOTIC AND LAPAROSCOPIC GASTRIC
CANCER SURGERY, A SIMPLE LIVER-SUSPENSION WITH GAUZE-SUTURE TECHNIQUE Yanghee Woo, MD, Kazutaka Obama, MD PhD, Tae-Il Son,
MD, Hyung Il Kim, MD, Woo Jin Hyung, MD PhD, Department of Surgery and Robot and Minimally Invasive Surgery Center at Yonsei University College of
Medicine
P070 DEEP FLEXION KINEMATICS WITH ROBOTIC MODULAR KNEE ARTHROPLASTY Toshifumi Watanabe, MD, Scott A Banks, PhD, Stefan Kreuzer,
MD, Kevin J Leffers, MD, Takeshi Muneta, MD PhD, Michael A Conditt, PhD, Jennifer A Jones, BS, University of Florida, Gainesville, Florida; Memorial Bone
and Joint Research Foundation, Houston, Texas; Tokyo Medical and Dental University, Tokyo, Japan; MAKO Surgical Corporation, Fort Lauderdale, Florida
P071 ROBOTIC SINGLE-SITE CHOLECYSTECTOMY: THE “SINGLE” PORT TO THE FUTURE OF SURGERY? FIRST EXPERIENCE FROM GREECE.
Konstantinos M Konstantinidis, MD PhD FACS, Savas C Hiridis, MD MSc, Periklis S Chrysocheris, MD, Peter C Hiridis, MD, Michael K Georgiou, MD, Athens
Medical Center
P072 LESSONS FROM AVIATION: CHECKLISTING IN FRONT OF THE ROBOTIC SURGICAL ’COCKPIT’. SURGICAL TECHNIQUE CHECKLISTS FOR
INTRAOPERATIVE USE WITH THE DAVINCI SYSTEM. Savas C Hiridis, MD MSc, Konstantinos M Konstantinidis, MD PhD FACS, Petros C Hiridis, MD,
Fotis Antonakopoulos, MD, Dimitris Mousiolis, MD, Kouloufakou Kalliopi, MD, ATHENS MEDICAL CENTER
P073 ROBOTIC TRAINING : LESSONS TO BE LEARNED FROM THE AERONAUTIC PRACTICE ? J. Hubert, MD, G Herrmann, M Perez, MD, C Perrenot,
C Waked, MD, N Hubert, MD, N Tran, MD, 1) Department of Urology, CHU Nancy-Brabois 54511 VANDŒUVRE les NANCY, FRANCE. 2) School of surgery :
UHP-Nancy1, 54500 VANDŒUVRE les NANCY, FRANCE. 3) Air France company, Paris

34 6 TH ANNUAL MIRA CONGRESS May 11-13, 2011

 P074 ROBOTIC-ASSISTED GYNECOLOGIC/ONCOLOGIC SURGERY: EXPERIENCE OF EARLY CASES IN A SAUDI ARABIAN TERTIARY CARE
FACILITY Ismail A Al-Badawi, MD, Murad Z Al-Aker, MD, Ibtihal Bukhari, MD, Sarfraz Ahmad, PhD, Jamal Alsubhi, MD, King Faisal Specialist Hospital &
Research Center, Riyadh 11211, Saudi Arabia
P075 ROBOTIC ASSISTED SURGICAL STAGING FOR OVARIAN CANCER IN A PREGNANT WOMAN Ismail A Al-Badawi, MD, Murad Z Al-Aker, MD,
Wesam Kurdi, MD, Jamal Alsubhi, King Faisal Specialist Hospital & Research Center, Riyadh 11211, Saudi Arabia
P076 SURGICAL OUTCOMES WITH ROBOTICS AND MORBIDLY OBESE WOMEN Pamela J Stone, MD, Mohamed Ismaeil, MD, Alexander Burnett, MD,
University of Arkansas for Medical Sciences
P077 ROBOTIC EXTRAPERITONEAL ENDOSCOPIC AORTIC LYMPHADENECTOMY: AN EXPERIMENTAL PIG MODEL Dominique Lanvin, MD,
Monique Bertrand, MD, CSTAR (Canadian Surgical Technologies & Advanced Robotics) Lawson Health Research Institute, London, Ontario, Canada
P078 POSTOPERATIVE PAIN MEDICATION REQUIREMENTS IN PATIENTS UNDERGOING ROBOTICALLY ASSISTED AND STANDARD LAPAROSCOPIC
PROCEDURES FOR NEWLY DIAGNOSED ENDOMETRIAL CANCER Mario M Leitao, MD, Ginger J Gardner, MD, Gabriel Briscoe, Priyal Dholakiya, Kevin Santos,
Elizabeth Jewell, MD, Nadeem R Abu-Rustum, MD, Yukio Sonoda, MD, Richard R Barakat, MD, Vivek Malhotra, MD, Memorial Sloan-Kettering Cancer Center
P079 VAGINAL CUFF DEHISCENCE AFTER ROBOTICALLY ASSISTED PROCEDURES REQUIRING A COLPOTOMY Mario M Leitao, MD, Ginger J
Gardner, MD, Gabriel Briscoe, Elizabeth Jewell, MD, Nadeem R Abu-Rustum, MD, Carol L Brown, MD, Dennis S Chi, MD, Yukio Sonoda, MD, Douglas A
Levine, MD, Richard R Barakat, MD, Memorial Sloan-Kettering Cancer Center
P080 INTEGRATION AND TRAINING OF ROBOTICALLY-ASSISTED SURGERY IN A GYNECOLOGIC ONCOLOGY FELLOWSHIP PROGRAM Mario M
Leitao, MD, Ginger J Gardner, MD, Gabriel Briscoe, Kevin Santos, Elizabeth Jewell, MD, Carol L Brown, MD, Dennis S Chi, MD, Richard R Barakat, Memorial
Sloan-Kettering Cancer Center
P081 COLPOTERES SUSPENSION PROCEDURE John S Missanelli, DO, Grossmont Obstetrics and Gynecology
P082 INTRODUCTION OF ROBOTIC TECHNOLOGY FOR HYSTERECTOMY: ANALYSIS OF FEASIBILITY AND COMPLICATION RATES DURING
THE FIRST 4 YEARS OF USE Sidonia-Maria Saceanu, Resident Doctor, Nicola Pluchino, Dr, Letizia Freschi, Dr, Vito Cela, Dr, Marcela Goga, Dr, Lavinia
Dobrescu, Dr, Alexandru Goganau, Dr, Andrea Genazzani, Professor, Department of Reproductive Medicine and Child Development Division of Gynecology and
Obstetrics University of Pisa,Italy,Department of Gynecology and Obstetrics II, University Hospital Craiova,Romania
P083 ROBOTIC SURGICAL REMOVAL OF BLADDER ENDOMETRIOSIS -THE NEW GOLD STANDARD? Sidonia-Maria Saceanu, Dr, Nicola Pluchino,
Dr, Letizia Freschi, Dr, Alexandru Handabureac, Dr, Ayed Kamal, Dr, Alexandru Goganau, Dr, Vito Cela, Dr, Andrea Genazzani, Professor, Department of
Reproductive Medicine and Child Development Division of Gynecology and Obstetrics University of Pisa,Italy,Department of Gynecology and Obstetrics II,
University Hospital Craiova,Romania
P084 ROBOTIC ASSISTED LAPAROSCOPIC ABDOMINAL CERCLAGE: A NOVEL APPROACH Donna Brown, MD, Frank Craparo, MD, Mark Shahin, MD,
Larry Barmat, MD, Abington Memorial Hospital, Abington, PA
P085 ROBOT-ASSISTED VERSUS OPEN RADICAL HYSTERECTOMY: A COMPARISON OF ONE SURGEON’S OUTCOME. Bilal M Sert, MD, Vera Abeler,
MD PhD, The Norwegian Radium Hospital
P086 MORBID OBESITY OUTCOMES IN ROBOTIC GYNECOLOGIC SURGERY Taryn Gallo, MD, Masoud Azodi, MD, Yale New Haven Health/Bridgeport Hospital
P087 INCIDENCE OF VAGINAL CUFF DEHISCENCE WITH ROBOTIC HYSTERECTOMY: AN ANALYSIS OF 500 CASES Taryn Gallo, MD, Masoud Azodi,
MD, Yale New Haven Health / Bridgeport Hospital
P088 USE OF INTRAUTERINE MANIPULATOR AND ITS EFFECT ON LYMPHOVASCULAR SPACE INVASION IN ROBOTICALLY ASSISTED
ENDOMETRIAL CANCER STAGING Rhoda A Raji, MD, Karim ElSahwi, MD, Charlene Hooper, MD MPH, Elena Ratner, MD, Dan-Arin Silasi, MD, Peter E
Schwartz, MD, Thomas J Rutherford, MD PhD, Masoud Azodi, MD, Yale-New Haven Hospital, New Haven, CT, 06520 , USA.
P089 SINGLE PORT HYSTERECTOMY: CONVERTING FROM SINGLE PORT LAPAROSCOPY TO SINGLE PORT ROBOTIC: THE GREEK EXPERIENCE
OF INTRODUCING INNOVATIVE SURGERY IN A FINANCIAL CRISIS ENVIRONMENT STEFANOS CHANDAKAS, MD MBA PhD, JOHN ERIAN,
FRCOG, Iaso Group of Hospitals, Athens, Greece and Attikon University Hospital, Athens, Greece
P090 ENDOMETRIAL CANCER AND ROBOTIC SURGERY: OUR EXPERIENCE MARIO VILLA, MD, MICHELA TERUZZI, MD, CIRO SPORTELLI, MD,
FRANCESCA FEI, MD, GIOVANNA CASPANI, MD, SARA SACCO, MD, ANTONIO PELLEGRINO, MD, Azienda Ospedaliera Ospedale Provinciale di Lecco, Italy
P091 LAPAROSCOPIC AND ROBOTICALLY ASSISTED HYSTERECTOMY. OUR EXPERIENCE IN A SERIES OF 8 CONSECUTIVE CASES. Konstantinos
P Mirillas, MD, Petros C Hiridis, MD, Bisbikis Dimitris, MD, Savas C Hiridis, MD MSc, Perikles S Chrysocheris, MD, Konstantinos M Konstantinidis, MD PhD
FACS, Athens Medical Center
P092 ROBOTIC REPAIR AND REINFORCEMENT WITH PERMACOL® OF GIANT HIATAL HERNIA IN AN INFANT Eun Young Chang, MD, Jae Ho
Shin, MD, Hye Kyung Chang, MD PhD, Jung-Tak Oh, MD PhD, Seok Joo Han, MD PhD, Department of Pediatric Surgery, Severance Children’s Hospital, Yonsei
University College of Medicine, Seoul, Korea
P093 THE EXPERIENCE OF THE 2ND UROLOGY DEPARTMENT AT HYGEIA HOSPITAL IN ROBOTIC SURGERY ALEXANDROS MOKAKOS, MD,
SPIRIDON MARTINIS, MD, EMANUEL PANAGIOTOU, MD, 2nd Department of Urology, Hygeia Hospital, Athens Greece
P094 ROBOTIC-ASSISTED RADICAL PROSTATECTOMY IN MEN OVER 75 YEARS OF AGE. SURGICAL, ONCOLOGIC AND FUNCTIONAL
OUTCOMES. Apostolos P Labanaris, MD PhD, Vahudin Zugor, MD PhD, Jorn H Witt, MD PhD, Department of Urology and Pediatric Urology – Prostate Center
Northwest, St. Antonius Medical Center, Gronau, Germany
P095 EVALUATION OF SURGICAL MARGIN STATUS IN PATIENTS UNDERGOING ROBOTIC-ASSISTED RADICAL PROSTATECTOMY FOR LOW,
INTERMEDIATE, AND HIGH-RISK PROSTATE CANCER. Apostolos P Labanaris, MD PhD, Vahudin Zugor, MD PhD, Jorn H Witt, MD PhD, Department of
Urology and Pediatric Urology – Prostate Center Northwest, St. Antonius Medical Center, Gronau, Germany
P096 ROBOTIC RADICAL AND PARTIAL NEPHRECTOMY Nick Pardalidis, Nick Andriopoulos, Aggelos Karamanis, Eleni Kosmaoglou, Athens Medical
Centre, Athens, Greece
P097 RETROSPECTIVE STUDY ON ANATOMIC VARIATIONS OF RENAL VESSELS BASED ON LAPAROSCOPIC-ROBOTIC SURGERY EXPERIENCE
Chady Waked, MD, Ibrahim-Michel Karam, MD, cyril Perrenot, MD, Manuella Perez, MD, Pascal Eschwege, MDPhD, Michel Claudon, MDPhd, Jacques Hubert,
MDPhD, Department of Urology, Brabois Hospital, Nancy, France

www.mirasurgery.org 35
Poster Abstracts
P001: ROBOTICS ENABLES A MINIMALLY INVASIVE APPROACH TO
RIGHT SIDED EPIPHRENIC DIVERTICULUM Barbara Tempesta, CRNP,
Marc Margolus, MD, Eric Strother, CSA, Farid Gharagozloo, MD Washington
Institute Of Thoracic And Cardiovascular Surgery; The George Washington
University Medical Center
Introduction: The surgical treatment of an epiphrenic diverticulum involves
resection of the diverticulum as well as a long esophageal myotomy. Although
minimally invasive approaches have been used with left sided epiphrenic
diverticulum, the treatment of a right sided diverticulum has required a
thoracotomy. The unique capabilities of the robot, specifically three dimensional
visualization and greater maneuverability in a confined space, enables a
minimally invasive right sided approach to patients with a right esophageal
diverticulum and single stage diverticulectomy and esophageal myotomy.
Methods: Over an 18 month period, 3 patients underwent robotic
diverticulectomy and esophageal myotomy through the right chest. Success
of the myotomy was judged by intra-operative EGD and post op esophagram.
Patients were scored symptomatically both subjectively by interview and
objectively by Viscik classification of pre-op and post operative symptoms.
Patients underwent rigorous follow up for recurrence of symptoms.
Results: There were 2 women and I man, mean age 56 years. There was no
gastroesophageal reflux and all patients were judged to be Viscik I in the post-
op period. There was complete relief of dysphagia. There were no esophageal
perforations. There was no recurrence of symptoms at a mean follow up of 12
months. Pre-operatively all patients had esophagitis. This esophagitis persisted
for a mean of 6 months in 2 patients with complete resolution. Post-operatively
one patient underwent a laparoscopic cholecystectomy.
Conclusion: Robotics obviates the need for an open surgical approach in this
subset of patients with right sided epiphrenic diverticulum and is associated with
excellent results.
P002: ROBOTIC APPROACH TO A LEFT SIDED EPIPHRENIC
DIVERTICULUM Farid Gharagozloo, Marc Margolis, MD, Eric Strother,
CSA, Barbara Tempesta, CRNP Washington Institute Of Thoracic And
Cardiovascular Surgery; The George Washington University Medical Center
Introduction: Non-robotic minimally invasive approaches, either by laparoscopy
or thoracoscopy, in patients with a left sided epiphrenic diverticulum is
associated with complications related to esophageal perforation and the success
of the myotomy. A left thoracic approach is preferable to a trans-abdominal
approach in these patients. Robotics enables a minimally invasive trans-thoracic
approach to diverticulectomy and distal esophageal myotomy in patients with
left sided diverticuli.
Methods: We present a video of such an approach in a 44 year old female
with an epiphrenic diverticulum. The patient underwent robotic left sided
diverticulectomy and distal esophageal myotomy.
Results: There was excellent relief of dysphagia and no gastroesophageal reflux.
The post-operative course was complicated by a pulmonary embolus and
collapse of the left lower lobe, both of which responded to conventional therapy.
Conclusion: Intermediate term follow up by interview and an esophagram
revealed a normal esophagus with easy passage of contrast through the
gastroesophageal junction.
P003: ROBOTIC LAPAROSCOPIC GASTROESOPHAGEAL
VALVULOPLASTY FOR THE TREATMENT OF GASTROESOPHAGEAL
REFLUX DISEASE Farid Gharagozloo, MD, Eric q Strother, CSA, Marc
Margolis, MD, Barbara Tempesta, CRNP Washington Institute Of Thoracic And
Cardiovascular Surgery; The George Washington University Medical Center
Objective: The Nissen fundoplication is the most common procedure performed
for gastroesophageal reflux disease. The Nissen procedure wraps the fundus of
the stomach around the distal esophagus and is associated with dysphagia and
gas bloat in a subset of patients. The normal antireflux barrier consists of a valve
which is formed by the intussusception of the esophagus into the stomach at the
gastroesophageal (GE) junction. Creation of a gastroesophageal valve using the
surgical robot may enable a more physiologic anti-reflux procedure associated
with lower incidence of dysphagia and gas bloat.
Methods: During a 52 month period, 30 patients (11 men, 19 women, mean age 47
years) with gastroesophageal reflux disease underwent robot-assisted laparoscopic
36
Belsey fundoplasty. All patients underwent pre-operative manometry and 24 hour
pH study. The procedure was performed through five laparoscopic ports. The
hiatus was closed anteriorly and posteriorly. The esophagus was intussuscepted
into the stomach by 2 cm for 270 degrees. Results were assessed by preoperative
and postoperative endoscopy, manometry, 24 hour pH study, UGI study,
subjective symptom questionnaire, and objective Viscik grading.
Results: Indications for surgery were intractability and pulmonary complications.
Median OR time was 3 hours. Median hospitalization was 1 day. Mean follow
up was 36 months. Subjective symptomatic improvement decreased from 8.3
+/- 0.6 to 0.7 +/- 0.2 (p<0.05). 95% were Viscick I. 23 patients (76%) had
transient postoperative dysphagia which resolved by the third postoperative
week. At follow up there was no gas bloat or long term dysphagia and there was
no recurrence of hiatal hernia.
Conclusions: Robotic laparoscopic gastroesophageal valvuloplasty recreates the
normal anti-reflux barrier. This procedure is associated with a low incidence of
gas bloat and dysphagia. The results appear to be sustained in a medium term
follow up. Although greater experience is necessary, a robotic laparoscopic
gastroesophageal valvuloplasty may represent a more physiologic alternative to
the Nissen fundoplication.
P004: ROBOT-ASSISTED THORACOSCOPIC RIGHT UPPER
LOBECTOMY FOR EARLY STAGE LUNG CANCER - A VIDEO
PRESENTATION OF ROBOT POSITIONING AND OPERATIVE
TECHNIQUE Farid Gharagozloo, Marc Margolis, MD, Eric Strother,
CSA, Barbara Tempesta, CRNP Washington Institute Of Thoracic And
Cardiovascular Surgery; The George Washington University Medical Center
Objective: Robotic surgical systems have the potential to enhance thoracoscopic
lobectomy by facilitating complex 3-D maneuvers and fine dissection. This
video illustrates the use of the da Vinci surgical robot for thoracoscopic right
upper lobectomy in patients with early stage lung cancer.
Methods: This patient underwent a robot assisted video-assisted right upper
lobectomy and complete mediastinal nodal dissection for early stage lung cancer.
Conclusion: Robotics enables minimally invasive anatomic lobectomy comparable
in technique to lobectomy by thoracotomy. Robotic lobectomy is associated
with low morbidity and mortality. Low local recurrence rate and pathologic
upstaging may be due to enhanced visualization and more accurate and extensive
mediastinal and hilar nodal dissection afforded by the robot. The results
improve significantly with greater experience.
P005: DECREASED POST-OPERATIVE PAIN WITH A NOVEL PORT
CLOSURE IN THORACIC ROBOTIC SURGERY Eric Strother, CSA, Marc
Margolis, MD, Barbara Tempesta, CRNP, Farid Gharagozloo, MD Washington
Institute Of Thoracic And Cardiovascular Surgery; The George Washington
University Medical Center
Introduction: Postoperative pain relief is paramount for decreasing
complications after thoracic surgery. Although a number of techniques are
used for relief of pain following video assisted and robotic thoracic surgery,
post operative pain remains a significant consideration. After minimally
invasive thoracic surgery, the soft tissues are re-approximated at the entry
sites. However, traditionally the intercostal space is not re-approximated.
As rib movement and intercostal nerve stimulation has been shown to be a
significant component of post thoracotomy pain syndrome, we hypothesize
that re-approximation of the intercostal space and rib fixation may decrease
pain following video assisted and robotic thoracic surgery.
Methods: Over 6 months, 50 patients underwent rib re-approximation (RA) at
the time of minimally invasive thoracic surgery. At each of the entry sites, the
rib above and below the intercostal entry site was drilled. A number 3 vicryl
suture was passed and tied thereby reapproximating the ribs and closing the
intercostal space. Efficacy of post operative pain control was evaluated in terms
of a Likert pain scale ranking, length of stay, and return to activities of daily
living. The data was collected prospectively and evaluated retrospectively. This
surgical cohort was then compared to a similar group of patients who underwent
closure without rib approximation after minimally invasive thoracic surgery
(control, C).
Results: Post-operative Likert pain scale on POD 1, 14, and 30 was 6, 4, and 1.5
for RA versus 7.7, 6.8, 4.0 for C. Median length of stay was 3 days for RA, 4 for
C. Return to normal activities was decreased by 20% between the two cohorts.
6 TH ANNUAL MIRA CONGRESS May 11-13, 2011
 Conclusion: Rib approximation after video assisted and robotic surgery is associated
with decreased pain and earlier return to normal activities. Although greater
experience is necessary, rib approximation as part of the routine closure of port sites
should be considered in all patients undergoing minimally invasive thoracic surgery.
P006: ROBOTIC SEGMENTECTOMY OF EARLY STAGE LUNG CANCER
Farid Gharagozloo, Marc Margolis, MD, Eric Strother, CSA, Barbara Tempesta,
CRNP Washington Institute Of Thoracic And Cardiovascular Surgery; The
George Washington University Medical Center
Introduction: Anatomic segmentectomy has been advocated as a curative
procedure in selected patients with non-small cell lung cancer. We investigated
the feasibility and suitability of robotic video assisted thoracoscopic
segmentectomy and complete mediastinal exeneration as a less invasive
alternative to the open procedure. Robotic anatomic segmentectomy and
complete mediastinal exeneration was performed in patients with impaired lung
function and small periphery located tumors.
Methods: We performed a retrospective review of 48 patients who underwent
robotic video assisted thoracic surgery segmentectomy for early stage lung cancer
in a 60 month period at our institution. All patients underwent robotic dissection
of the artery, vein, and the bronchus with division of the respective segmental
structures. In addition a complete mediastinal nodal exeneration was performed
with removal of subcarinal, paraesophageal, paratracheal, and inferior pulmonary
ligament lymph nodes. Inclusion criteria was a pre-operative clinical T1 disease in
a patient with impaired pulmonary function (FEV1 < 800 or DLCO < 50).
Results: There were 26 men, 22 women, mean age 74 years. All patients underwent
R0 resection. Operating room time was 3 hours, no statistical difference between
robotic segmentectomy and robotic lobectomy. Median hospital length of stay was 6
days. All patients underwent segmentectomy for early stage lung cancer. Histology
was squamous cell (11 patients), adenocarcinoma (20 pts), adenosquamous (9),
basaloid (1), giant cell (2), and bronchoalveolar (5). Tumor size 2.0 cm or less was
25 patients, 23 were > 2.0 cm. Complications included atrial fibrillation, atelectasis
requiring bronchoscopy, and C-Doff infection. There were no mortalities.
Conclusions; Robotic video assisted segmentectomy is a safe procedure which may
represent a less invasive oncologic procedure to patients with small lung cancers
and limited cardiopulmonary reserve.
P007: ROBOTIC SURAL NERVE GRAFT FOR REVERSAL OF THORACIC
SYMPATHECTOMY Farid Gharagozloo, Marc Margolis, MD, Eric Strother,
CSA, Barbara Tempesta, CRNP Washington Institute Of Thoracic And
Cardiovascular Surgery; The George Washington University Medical Center
Title: Robotic video assisted reconstruction of the sympatheti chain for reversal
of compensatory hyperhydorsis after sympathectomy.
Introduction: Compensatory hyperhydrosis after thoracic dorsal sympathectomy
is a common recongnized complication. Sympathetic chain reconstrcution
using peripheral nerve grafts has been advocated as a means of reversing
debilitating compensatory hyperhydrosis. Improvements after reconstruction
have been reported to a variable extent. The best results have been obtained by
thoracotomy and nerve grafting using an operating microscope. We reasoned
that the magnified three dimensioanl high definition visualization possible with
the robotic systems and the superb instrument maneuverability can enable nerve
grafting using the robot and minimally invasive techniques, thereby obviatring
the complications associated with a thoracotomy.
Methods/Results: A 26 year old female who had undergone throracsocopic
bilateral sympathectomy for primary hyperhydrosis presented with severe
compensatory hyperhydosis afffecting the lower chest, abdomen, and lower
extremities. The patient underwent a right trans thoracic robotic pocedure
using three non trocar 2 cm incisions. Sural nerve was harvested from the left
lower extremity. The sympathetic chain was dissected, the proximal portion
was identified just above the second sympathetic ganglion and the distal [portion
was identified just below the fourth sympathetic ganglion. The interposition
sural nerve graft wa sutured in place using the robot with 5-0 non-absorbablke
suture. The pleural space was drained. The patient was hospitalized for 4 days.
The immediate post operative course was uncomplicated.
Conclusion: Robotic interposition of a sural nerve graft is feasible for the
reconstruction of the sympathetic chain in patients with compensatory
hyperhydrosis after sympathectomy. This technique replicates the most
commonly performed procedure which has hereto required a thoracotomy.
www.mirasurgery.org
P008: ROBOTIC ASSISTED THORACOSCOPIC RESECTION OF
BRONCHOGENIC CYSTS Farid Gharagozloo, MD, Barbara Tempesta, CRNP,
Eric Strother, CSA, Marc Margolis, MD Washington Institute Of Thoracic And
Cardiovascular Surgery; The George Washington University Medical Center
Objectives: Bronchogenic cysts are usually adherent to adjacent structures which
makes a complete resection by conventional thoracoscopy difficult. The 3-D
visualization, greater instrument maneuverability, and more accurate dissection
of robotic surgical systems are ideally suited for the thoracoscopic resection of
mediastinal bronchogenic cysts.
Methods: From 1/07 – 12/10 15 patients underwent robotic resection of a
bronchogenic cyst. There were 9 women and 6 men. The robotic approach
was from the right pleural space in 10 patients (67%) and from the left in 5
patients (33%). Mean length of stay was 4 days. There was no conversion to a
thoracotomy.
Conclusions: Robotic surgery is highly suited for resection of bronchogenic cysts
as it allows for a more accurate thoracoscopic dissection of the cysts away from
the surrounding structures.
P009: ROBOTIC RELIEF TO THE MEDIAN ARCUATE SYNDROME Farid
Gharagozloo, MD, Marc Margolis, MD, Eric Strother, CSA, Barbara Tempesta,
CRNP Washington Institute Of Thoracic And Cardiovascular Surgery; The
George Washington University Medical Center
Introduction: The median arcuate ligament syndrome is a rare disorder which
results from compression of the celiac artery by aberrant diaphragmatic
muscular or fibrous bands. The syndrome is characterized by post prandial
abdominal pain, nausea, vomiting and weight loss. Surgical management has
included complete division of the median arcuate ligament. This procedure
has been performed by laparotomy and laparoscopy. We hypothesized that a
robotic laparoscopic approach would be superior by virtue of three dimensional
visualization and greater instrument maneuverability at the point of surgery.
Methods: A 24 year old female with history of post prandial abdominal pain,
nausea, and vomiting underwent robotic laparoscopic division of the arcuate
ligament. The syndrome was diagnosed by pre-operative computer tomography,
MRI, angiography, which demonstrated extrinsic compression at the origin of
the celiac artery. Five laparoscopic trocars were used. The celiac artery and
branch vessels were completely skeletanized. The compression of the celiac
artery appeared to result from an elongation of the left limb of the esophageal
crus of the diaphragm.
Results: Post op course was uncomplicated. A post operative CT scan demonstrated
no residual stenosis. The patient’s symptoms improved dramatically in the
immediate post operative period. Post prandial abdominal pain resolved
immediately after surgery but nausea persisted an additional 4 months.
Conclusion: Robotic surgical systems present a significant technological advance
to conventional laparoscopic instruments. This advance is most notable in the
management of patients with median arcuate ligament syndrome who require
highly accurate instrument movement and three dimensional visualization in a
very confined space.
P010: SUBPLEURAL CATHETER PLACEMENT FOR POST-OPERATIVE
PAIN - TECHNIQUE AND INTERMEDIATE TERM RESULTS Barbara
Tempesta, CRNP, Marc Margolis, MD, Eric Strother, CSA, Farid Gharagozloo,
MD Washington Institute Of Thoracic And Cardiovascular Surgery; The
George Washington University Medical Center
Objectives: Postoperative pain relief is paramount for decreasing complications
after thoracic surgery. Systemic narcotics and epidurals provide excellent relief
but are hampered by complications such as somnolence, insertion and infusion
side effects, and return of pain after removal. Direct prolonged intercostal
pain relief with continuous infusion of local anesthetic is an alternative to
conventional pain relief techniques.
Methods: Over a 62 month period 300 patients who underwent thoracic surgery
underwent this technique for subpleural infusion of a local anesthetic via a
specially created subpleural tunnel where two five inch catheters are inserted,
covering intercostal spaces two through eight. 0.25% Bupivicaine is infused
at 2cc/hr via each catheter for a ten day duration. Efficacy of pain control was
evaluated in terms of a Likert pain scale ranking as well as length of stay and
return to activities of daily living.
37
Poster Abstracts
Results: Post-operative pain ranked on post-op day 1, 14 and 30 was 7.7, 6.8, and
4.0 respectively for the control group and 5.0, 3, and 1 for the study group; all p
< 0.05. Median length of stay was 4 days and median return to normal activities
was 17 days. Incidence of long term pain syndrome was less than 3%.
Conclusions: Prolonged subpleural catheter infusion of local anesthetic with
a system devised for outpatient use may represent a superior pain control
technique with greater patient satisfaction and shorter hospitalization and lower
incidence of post thoracotomy pain syndrome.
P011: PROLONGED OPERATIVE TIME IN ROBOTIC TOTALLY
ENDOSCOPIC TOTALLY ENDOSCOPIC COR ONARY BYPASS SURGERY
- IS IT AN ISSUE? Dominik Wiedemann, Nikolaos Bonaros, Thomas Schachner,
Felix Weidinger, Eric Lehr, Mark Vesely, Guy Friedrich, Johannes Bonatti 1
University Clinic of Cardiac Surgery, Innsbruck Medical University, Austria 2
Division of Cardiac Surgery, Department of Surgery, University of Maryland,
USA 3 Division of Cardiology, University of Maryland, USA 4 Department of
Cardiology, Innsbruck M
Introduction: Robotically assisted Totally Endoscopic Coronary Artery Bypass
Grafting (TECAB) is the only viable option to perform endoscopic coronary
surgery. TECAB is requires learning curves and long operative times. The
aim of this study was to evaluate the effect of longer operation times on the
perioperative outcome of patients undergoing TECAB.
Patients & Methods: From 2001 to 2009 A total of 325 consecutive patients
underwent TECAB Correlations between operation times with preoperative,
intra-operative and early postoperative parameters were investigated ROC
analysis was used to define the threshold of the procedure duration above
which longer a Intensive Care Unit (ICU) stay and ventilation time was needed.
Demographic data, intra- and postoperative parameters as well as survival data
of patients with and without prolonged operation times were compared and risk
factors for prolonged operation times were identified.
Results: Patients with prolonged operation times had more often endoscopic
multivessel revascularzation (p<0.001) and underwent beating heart TECAB
more often (p=0.023). Other preoperative parameters such as EuroScore,
Body Mass index, age, gender, ejection fraction, NYHA-stadium, serum-
creatinine were not associated with longer operative times. . The incidences of
intraoperative technical difficulties and conversions (p<0.001) were higher in
the group of patients with longer operation times. Longer operation times were
associated with prolonged ICU-stay, mechanical ventilation times, hospital stay
and requirement of PRBC and FFP’s . ROC analysis showed that operation times
>445 min and >478min predicts prolonged ICU stay (>48h) and mechanical
ventilation time (>48h) respectively. Additionally, patients with a procedure
duration >478 min had a longer hospital stay, higher rates of renal failure,
pneumonia, superficial wound infections, sepsis, and hospital mortality. Kaplan-
Meier analysis revealed decreased survival rates in patients with operation times
>477.5 min (98.8% vs. 93.8%, p=0.02) at a median follow up of 20 months
(0-96).
Conclusion: Multivessel disease and conversion TECAB are independently
associated with longer operative times. Longer operation times significantly
influence early postoperative outcome variables after TECAB. Intraoperative
technical difficulties and conversion to sternotomy as well as lower mid-term
survival were associated with longer operation times. Patients with shorter OR-
times had survival benefits.
P012: EARLY AND MIDTERM RESULTS OF TOTALLY ENDOSCOPIC
CORONARY ARTERY BYPASS GRAFTING ON BEATING HEART
Changqing Gao, MD PLA General Hospital
Objectives: Despite the early introduction of totally endoscopic coronary artery
bypass on beating heart (BH TECAB), only a limited number of cases have
been performed. The limiting factor has been the concern about safety and
graft patency of the anastomosis. This study describes our experience with BH
TECAB with robotic assistance and its early and midterm results.
Methods: In 365 cases of robotic cardiac operations, 162 patients underwent
robotic CABG on beating heart, in which 60 patients (46/M, 14/F) underwent
BH TECAB. Mean age was 56.97 ± 9.7 (33 to 77) years. LIMA to LAD
anastomosis was performed using U-Clip.
Results: 58 TECAB procedures were completed, in which 16 patients received
hybrid procedures. Two patients were converted to minithoracotomy. The
38
average LIMA harvesting and anastomosis times were 31.3 ± 10.5 (18~55)
min and 11.3 ± 4.7 (5~21) min respectively. The mean operating room
and operation times were 336.1 ± 58.5 (210~580) min and 264.8 ± 65.6
(150~420) min respectively. The drainage was 164.9 ± 83.2 (70~450) ml.
Before discharge, 50 patients underwent angiography and 8 patients underwent
CTA scan, and the study showed that graft patency was 100% and unexpectedly,
LIMA graft developed a collateral branch in 2 patients. After discharge, all
patients were followed up by CTA scan, average follow-up time was 12.67±9.43
(1 to 40 months). One patient had gastric bleeding after surgery.
Conclusions: BH TECAB is a safe procedure in selected patients and produces
excellent early and midterm patency of anastomosis.
P013: ROBOTIC TOTALLY ENDOSCOPIC CORONARY ARTERY BYPASS
GRAFTING FOR SPONTANEOUS CORONARY ARTERY DISSECTION
Brody Wehman, MD, Eric Lehr, MD PhD, Ratnakar Mukherjee, MD, Alina
Grigore, MD, Bartley Griffith, MD, Johannes Bonatti, MD University of
Maryland Medical Center
Objective. Spontaneous coronary artery dissection (SCAD) is a rare but
potentially life-threatening cause of acute coronary syndrome known to affect
young adults without coronary artery disease risk factors. Management of
SCAD may demand coronary bypass surgery depending on the location of the
dissection and clinical presentation. Robotic totally endoscopic coronary artery
bypass grafting (TECAB) for SCAD has not been reported.
Methods. A 58 year old male patient presented with acute chest pain while being
evaluated for acute cholecystitis. On coronary angiography he was found to
have a dissection of the middle portion of his left anterior descending (LAD)
artery. A ventriculogram showed decreased anterior wall motion and surgical
revascularization was indicated. A prophylactic intraaortic balloon pump was
placed. Totally endoscopic coronary artery bypass grafting was performed using
the da Vinci surgical robot, the left internal mammary artery was harvested and
sutured to the LAD.
Results. The anastomosis was performed in a dissection free distal portion of
the LAD. An on table angiogram showed a patent graft and an expanded true
lumen of the dissected LAD with adequate antegrade and retrograde filling. The
postoperative course was uncomplicated and the patient was discharged to home
on postoperative day five. At one month following the operation, the patient was
asymptomatic and had returned to his baseline activity level without need for
sternal precautions.
Conclusions: We describe a first successful case of completely endoscopic
coronary surgery using the da Vinci system in a patient with SCAD and acute
anterior wall ischemia. The case demonstrates that TECAB can be carried out in
difficult subsets of patients undergoing coronary bypass grafting.
P014: ROBOTIC APPROACH TO GIANT HIATAL HERNIAS WITH
PRIMARY REPAIR OF THE DIAPHRAGMATIC HERNIA Sigrid Bairdain,
MD, Marc Margolis, MD, Barbara Tempesta, CRNP, Eric Strother, CSA,
Farid Gharagozloo, MD Washington Institute of Thoracic and Cardiovascular
Surgery; The George Washington University Medical Center
Introduction: Giant hiatal hernias with intrathoracic stomach have not been
amenable to repair using laparoscopy. Conventionally the surgical approach to
these large hernias has been through a thoracotomy or laparotomy or the use of
a hiatal patch with laparoscopy. Historically, independent of the approach, the
results of surgical repair have been disappointing. By virtue of three dimensional
visualization and greater effector instrument maneuverability, the robot can
allow for a laparoscopic approach for the dissection of the intrathoracic stomach
and primary repair of the giant hiatal hernia.
Methods: In a 10 month period, 5 patients with an intrathoracic upside down
stomach and a giant hiatal hernia underwent a robotic laparoscopic approach.
The robot was introduced through 4 trocars. The intra thoracic dissection of the
hernia sac and the stomach was performed robotically. The right and left crus were
dissected, hiatal closure was performed primarily using 0 Ethibond suture with
pledgets of vicryl mesh. A concomitant anti-reflux procedure was performed in all
patients. The success of the procedure was assessed by intra-operative endoscopy,
post-operative esophagram. Subjective symptoms were assessed by a symptom
interview. Objective symptoms were assessed by third party Viscik grading.
Results: There were 2 men, 3 women, mean age 56 years. The procedure was
assessed to be successful in all patients based on endoscopy and esophagram. All
6 TH ANNUAL MIRA CONGRESS May 11-13, 2011
 patients were asymptomatic and were graded as Viscik I at 1 day, 2 weeks, and
10 months. There was no recurrence of hiatal hernia.
Conclusions: Robotics enables a complete dissection of the hernia sac and
reduction of intrathoracic stomach in patients with giant hiatal hernias.
Although greater experience is necessary, robotics may represent a more viable
minimally invasive approach with primary closure of the hiatus in patients with
giant hiatal hernias.
P015: SHORT-TERM ANGIOGRAPHIC RESULTS OF ROBOTICALLY
ASSISTED CORONARY ANASTOMOSIS USING CONVENTIONAL AND
CT-ANGIOGRAPHY Nikolaos Bonaros, MD, Felix Weidinger, MD, Benedikt
Hofauer, MD, Gudrun Feuchtner, MD, Fabian Plank, Guy Friedrich, MD, Eric
Lehr, MD, Johannes Bonatti, MD, Thomas Schachner, Md Department iof
Cardiac Surgery, Innsbruck Medical University
Background: Robotic technology enables totally endoscopic coronary artery
bypass grafting on the arrested or on the beating heart. The aim of the study
was to investigate the short-term quality of robotically sutured anastomoses by
means of invasive graft angiography and multi-detector CT angiography.
Methods: Two hundred seventy six patients received robotically sutured coronary
anastomoses using the daVinci telemanipulation system. 140 (51%) and 264
(96%) underwent postoperative conventional graft angiography and CT
angiography respectively. The vast majority of the patients underwent single
or double arrested heart TECAB (207/276), 21 patients had a BH TECAB,
12 and 3 patients received a sequential or Y-grafting respectively. 48 patients
underwent robotically sutured anastomosis through conventional sternotomy.
Results: The median interval from surgery to coronary angiography was 3
months (0.25-72 months). The median interval to CT angiography was also 3
months (0.25-8 months). 160 /319 (50%) robotically sutured anastomoses were
evaluated by conventional graft angiography. There were 3 anastomoses with
a non-significant angiographic stenosis, 2 anastomoses with a relevant stenosis
>50%, 1 anastomotic occlusion, and 1 anastomosis to an incorrect target
vessel. CT angiography revealed 1 anastomotic stenosis, 2 grafts with a string
phenomenon as a result of competitive flow, 3 graft occlusions and one incorrect
grafting site. In 153/160 (96%) anastomoses evaluated by invasive angiography
a perfect result was detected. Accordingly CT angiography revealed a perfect
postoperative result in 298/305 evaluated anastomoses (98%). CT angiography
could very well detect relevant angiographic stenosis, graft occlusion and
incorrect target vessel anastomosis in all cases.
Conclusions: Robotically sutured anastomosis on the arrested or on the beating
heart, as well as robotically-assisted composite grafting can be performed with
satisfying angiographic results. CT angiography can be used as an alternative for
postoperative evaluation of relevant anastomotic dysfunction.
P016: CAUSES AND CONSEQUENCES OF POSTOPERATIVE ATRIAL
FIBRILLATION IN TOTALLY ENDOSCOPIC CORONARY BYPASS
SURGERY Felix Weidinger, MD, Thomas Schachner, MD, Nikolaos Bonaros,
MD, Benedikt Hofauer, Eric J Lehr, MD, Mark Vesely, MD, David Zimrin,
MD, Johannes O Bonatti, MD Innsbruck Medical University, Department of
Cardiac Surgery; University of Maryland Medical Center, Division of Cardiac
Surgery
Background: Postoperative atrial fibrillation (AFib) is the most common
complication in patients undergoing coronary artery bypass grafting. Little
information concerning AFib following minimaly invasive cardiac surgery
is available. The aim of our study was to evaluate the incidence of AFib after
totally endoscopic coronary artery bypass grafting (TECAB) and to investigate
factors influencing its occurrence.
Methods: Between 2001 and 2010 we performed TECAB in 384 patients, 73%
male, aged 60 (37-90). Single vessel bypasses were performed in 280 patients,
and 104 received multivessel coronary revascularisation. Procedures were
performed without cardiopulmonary bypass in 80 cases and 164 patients
underwent a hybrid-intervention.
Results: A total of 59 patients (15.4%) developed AFib after TECAB. Univariate
analysis showed hypertension (p=0.005), and increased age (p=0.007), body
weight (p=0.006), body mass index (p=0.005), EuroSCORE (p=0.035), and
total TECAB operation time (p=0.01) to be significantly associated with atrial
fibrillation. We also found an increased incidence of AFib in patients undergoing
hybrid interventions (p=0.036) and beating heart TECAB (p=0.003). Age
www.mirasurgery.org
(p<0.001) and body weight (p=0.003) were the only predictors found to be
significant in multivariate analysis. Hospital mortality was 1.7% (1/59) in the
group of patients with atrial fibrillation and 0.6% (2/325) in the group that
showed no AFib after operation (p=n.s.). Hospital stay was 7 (4-54) days in
patients with AFib and 6 (2-33) days in patients without AFib (p=n.s.). There
was no significant 5 year survival difference in patients with and without
postoperative Afib (95.8% vs. 94.5%, p=n.s.).
Conclusion: We conclude that the incidence of postoperative AFib in TECAB
is relatively low. Age and body weight are the most important predictors
of postoperative AFib following TECAB. Short term clinical outcome
and intermediate term survival are similar in patients with and without
postoperative AFib.
P017: A COMPARATIVE STUDY ON ROBOTIC VERSUS OPEN RIGHT
HEMICOLECTOMY FOR CANCER F. Luca, MD, M. Valvo, MD, S.
Cenciarelli, MD, T. Leal Ghezzi, MD, M. Zuccaro, MD, S. Pozzi, MD, R. Biffi,
MD Division of Abdomino-Pelvic Surgery, European Institute of Oncology;
Milan, Italy
Introduction: Open right hemicolectomy has traditionally been considered as the
standard procedure for right-sided colonic tumors. The main objective of colon
cancer surgery is the removal of the primary tumor with an adequate number
of locoregional lymph nodes and surgical margin. The aim of our study was to
compare the surgical and pathological outcomes of patients with right-sided
colon cancers operated on by means of open and robotic surgery.
Methods & Procedures: 33 consecutive patients who underwent robotic right
hemicolectomy due to right-sided colon cancer from February 2008 were
retrospectively well matched with 102 patients operated on by open approach
from July 1994 to December 2002. Pathological and postoperative data were
included in a dedicated database and analyzed.
Results: mean operative time was longer in the robotic group (p < 0.001), 191.7
min (134 – 250) versus 136.2 (45 – 240) min in the open group. Estimated
intraoperative blood loss was lower in the robotic group: 6.1 ml versus 94.8 ml
(p < 0.001). Intra- and post-operative blood transfusions were more frequent
in the open group. Despite the similar number of lymph nodes retrieved in
both groups At least 15 or more lymph nodes were found in the specimen in 90
out of 102 patients (88.2%) treated by means of the open technique versus 33
patients (100%) in the robotic group (p = 0.038). The median postoperative
hospital stay was shorter in the robotic group, 5 versus 8 days (p < 0.001).
Although not statistically significant, an inferior percentage of infectious and
overall postoperative complications was observed among patients undergone
a robotic procedure. Three patients of the open group were reoperated due to
postoperative surgical complications, while no reintervention was needed in the
robotic group. No mortality was reported in both groups.
Conclusions: robotic right hemicolectomy is an oncologically safe and effective
procedure. The number of lymph nodes retrieved in the robotic group compared
to the open group of our series was more homogeneous and none of the patients
operated on with robotic technique had a suboptimal lymphadenectomy. Further
clinical trials are needed to confirm current evidence and determine whether
this can influence the prognosis. Robotics are likely to improve the as yet
poor adoption of minimally invasive surgery for colon cancer, estimated to be
between 6 and 12 % in western countries.
P018: THE LEARNING CURVE IN RECTAL RESECTION: IS IT FASTER IN
ROBOTICS THAN IN LAPAROSCOPY? Olivia Sgarbura, MD PhD, Serban
Vasile, MD, Mihai Eftimie, MD, Irinel Popescu, MD PhD FACS Fundeni
Institute of Digestive Diseases and Liver Transplantation, Bucharest, Romania;
University of Medicine and Pharmacy, Bucharest, Romania
Introduction: Robotic surgery has become an important approach in rectal cancer
while we were still waiting for the high level evidence concerning laparoscopic
rectal resections. One of the features frequently evoked as an advantage for robotic
surgery is the fast learning curve but current evidence is limited to the assessment
of the learning curve in robotic rectal resections. Our endpoint was to establish a
relation between the learning curves in the two minimally invasive approaches.
Material & Methods: A series of 89 consecutive patients with laparoscopic rectal
resections, operated between 1995-2010, and a series of 44 consecutive patients
with robotic rectal resections, operated between 2008-2010, were analyzed.
The interventions were performed for rectal adenocarcinoma and included low
39
Poster Abstracts
anterior resections and abdominoperineal resections. Demographic data, total
time and type of operation were recorded for all cases. Total time, console time
and docking time were recorded for robotic surgery. The results were analyzed
with SPPS 15.0 (Spss Inc.) based on raw data plotted by chronological cases and
cumulative sum analysis.
Results: The mean operating time was for 174 +/- 50 min for laparoscopy and
225+/-41 min for robotic surgery (p<0.001).Three phases were identified for
laparoscopic resections and only two for robotic resections. The first 20 cases
were the initial learning curve, the following 25 cases were the increasing
competence phase and the third phase consisting in 44 cases was the plateau
indicating achieved competence. In robotics, the first 20 cases represented the
learning curve but the following 24 cases indicated a plateau similar with the
third phase of laparoscopy.
Conclusions: The mastery of the robotic resection appears to be achieved after
the first 20 cases, earlier than in laparoscopy. However a long term study is
needed in order to assess a possible third phase in robotic resections that was not
observed due to the low volume of cases.
P019: ROBOTIC SURGICAL REMOVAL FOR RECURRENT PELVIC
TUMOR AFTER COLON CANCER RESECTION Sorin Paun, PhD, Roxana
Ganescu, MD, I Negoi, MD, Mihaela Burtea, MD, M Beuran, PhD Emergency
Hospital - Bucharest, Romania
Colon cancer, pelvis, recurrent tumor and surgical reintervention represent
challenges for actual robotic surgery. We are still in the time of beginning of
the robotic surgery and maybe some of the gold indications for such a surgical
technique could come from this area of medical interest.
This was the reason for us to operate a young female patient, 24 years old, one
year after a sigmoidectomy for well-differentiated adenocarcinoma T2N1M0G2
– a recurrent 2 cm diameter tumor was diagnosed in the pelvic-subperitoneal
space right-side from the middle rectum. A transperitoneal robotic approach
was performed at that time and the tumor was removed along with the abscess
nearby it. No intraoperative problems were encountered (easier adhesiolisys was
performed with robotic instruments) as well as no postoperative complications.
6 months after this robotic procedure, the patient developed another 2.5 cm
diameter recurrent tumor but with other localization – intraperitoneal lateral
superior to the colorectal anastomosis, 30 cm for the previous recurrent tumor
removed by robotic procedure. For the late situation, an open laparotomy was
performed to remove the new tumor.
Was the robotic approach the reason for the second tumor recurrence? Is it safe
to perform a robotic reintervention for colonic cancer? Obviously, pelvis is a
space to be approached by robotic device because of the maneuverability of the
instruments and enhanced view over the operating field – a video can proved it.
P020: ROBOTIC VERSUS LAPAROSCOPIC COLON AND RECTAL
SURGERY: EARLY COMPARISONS. Grace Montenegro, MD, Rami
Makhoul, MD, Vincent Obias, MD George Washington University
Introduction: Robotic colon and rectal surgery is a newly evolving field which
has gained recent interest. Due to the superb visualization, dissection, and
increased degrees of freedom, robotic surgery is being applied to a variety of
colon and rectal procedures. This study explores the initial experience in both
laparoscopic and robotic colectomy of a recent minimally invasive colorectal
surgery fellowship graduate.
Methods: We reviewed and compared the first consecutive 35 cases each of
laparoscopic and robotic colectomies performed by a single colorectal surgeon
at our institution from Dec 2008 to Oct 2010. Case distribution between the
Laparoscopic (L) and Robotic (R) groups were as follows: low anterior resection
(L-3, R-9), left hemicolectomy (L-5, R-4), right hemicolectomy (L-8, R-9),
subtotal colectomy (L-5, R-2), sigmoid colectomy (L-4, R-6), single-port
right hemicolectomy (L-7, R-3), transverse colectomy (L-2, R-1), Hartmann
(L-1) and abdominal perineal resection (R-1). Indications for surgery included
diverticular disease, tubular adenoma and adenocarcinoma. There was no
statistical difference among age, gender and BMI between the two groups.
Results: There were no deaths associated with either group. Complications for
both robotic and laparoscopic resections included postoperative ileus (L-1, R-3)
and bleeding (L-1, R-1). There was a single incidence of anastomotic leak and
necrotizing fascitis (extraction site) in the robotic group. 8 of 35 laparoscopic cases
were converted to open (possible anastomotic leak, dense adhesions, possible
40
ureteral injury and subcutaneous emphysema) while 2 of 35 robotic cases were
converted to laparoscopy (continuous air leak at camera port site). Utilizing
unpaired t-test, we compared median values for length of stay (L-4.5, R-5 days; p=
0.25), estimated blood loss (L-250cc vs R-125cc; p= 0.07), operative time (L-276
min vs R-309 min; p= 0.20) and lymph node harvest (L-18.5 vs R-18; p= 0.09);
there was no significant difference in the four categories among these four groups.
Conclusions: Our retrospective review demonstrates no significant difference
between robotic and laparoscopic colectomies comparing length of stay,
estimated blood loss, operative time and lymph node harvest. Our data suggests
robotic surgery is as safe as laparoscopy in experienced hands, and is an
acceptable modality for all types of colon resection.
P021: LESSONS LEARNT FROM INTRODUCTION OF ROBOTIC
COLORECTAL SURGERY IN A SPANISH UNIVERSITY HOSPITAL Elena
Ortiz-Oshiro, MD PhD, Angel Ramos Carrasco, MD PhD, Cristina Pardo
Martinez, MD PhD, Iris Sanchez Egido, PhD, Jaime González Taranco, PhD,
Jesus Alvarez Fernández-Represa, MD PhD Hospital Clinico San Carlos -
Universidad Complutense de Madrid
Introduction: Robotic colorectal surgery is currently gaining more and more
acceptance throughout the world due to their advantages respecting to
traditional laparoscopic approach (highly precise dissection, 3D vision,
multiarticulated instruments, great performance in complex cases and
suturing). Groups performing robotic colorectal procedures are learning
progressively to overcome the handicaps of Da Vinci system, as loss of haptic
feedback and the need of approaching 2-3 fields along the intervention. Our aim
is to present the evolution of our learning in robotic colorectal surgery, through
analysis of techniques and outcomes.
Material & Methods: From out of 281 robotic digestive procedures performed in
257 patients from July 2006 to December 2010, we have analysed colorectal
ones: indications, surgical procedures (technique, intraoperative results) and
postoperative outcomes, to reflect on our learning process.
Results: 2006 2007 2008 2009 2010 Hartman reversal 1 2 1 - - Right
hemicolectomy 1 11 7 2 1 Left hemicolectomy 2 17 7 4 - (L) Ant Rec Resect
- 1 1 4 10 72 colorectal procedures have been performed in our institution in
the mentioned period with four-arms standard Da Vinci system. The surgical
team comprised three surgeons, anesthesiologist and expert nurses. Indications
evolved from benign to malignant cases and from right and left colectomies to
rectal surgery. Time needed to setup the robot and docking, as well as time
needed to perform the procedures shortened with experience. There were no
conversion to laparoscopy, but 10 cases were converted to open (16.6%), mostly
due to technical drawbacks. Lack of feedback resulted in colonic perforation in
one case in the beginning. No other intraoperative incidents may be attributed
to robotic approach. Pathologic outcomes in oncologic cases did not differ from
those obtained in open procedures. 3 anastomotic leaks occurred after rectal
surgery (18.75%): two cases were managed conservatively (protective colostomy
in very low anterior resection) and one needed reintervention.
Conclusions: From this initial experience in robotic colorectal surgery we have
learnt that: - Laparoscopic previous experience is advisable - A stable and
expert team is essential - Good indications, adequate selection of patients and
application of planned protocols are the basis of success
P022: ROBOTIC COLECTOMIES: A SERIES OF 122 CASES Francesca
Bazzocchi, MD, Domenico Garcea, MD, Andrea Avanzolini, MD, Barbara
Perenze, MD Morgagni-Pierantoni Hospital - Forlì -Italy
Introduction: Robotic surgery has taken root from year to year, spreading to
several specialties. Indeed the drawback, which cut off the diffusion of robotics
among mininvasive digestive surgeons, was probably due to their major skill and
dexterity in the laparoscopic technique. Actually the robotic colectomies don’t
seem to offer a clear clinical benefit compared with the laparoscopic ones. The
aim of this study is to give value to the use of the Da Vinci surgical system in
right and left colectomies.
Methods & Procedures: From March 2007 through December 2010 we performed
122 totally robotic and robot-assisted colorectal resections: 31 for benign
diseases, 91 for malignant ones. The robotic procedures included: Right
Colectomy(RC) (n = 42), Abdominal-Perineal Resection (APR) (n=2), Left
colectomy(LC) (n=62), Sigmoidectomy(n= 5), Anterior Resection of the
Rectum (ARR) (n = 8) and Resection of Left Colic Flexure (LCFR) (n = 3).
6 TH ANNUAL MIRA CONGRESS May 11-13, 2011
 Results: The robotic indications were: diverticulosis (n=17), polyps (n=14) and
cancer (n=91). Mean operative time was 325 minutes (range, 172-570). The
conversion rate to open surgery was 7.4% (9 patients). The mean number of
harvested lymph-nodes in malignant pathologies was 22.1 (range, 8-61). The
median length of stay was 8.3 day. The overall anastomotic leakage rate was:
3.3%. The postoperative bleedings which required the reoperation were 2
(1.63%). There was one intraoperative complication in our series (bleeding).
Conclusions: Robotic surgery is the technologic reply to the human limitations
in laparoscopy and its choice will contribute to the advancement of mininvasive
surgery. It improves the performance of the surgeon and his working quality.
Actually there aren’t indisputable proofs that the robotic system assures an
obvious clinical benefit in colon resection. Further studies comparing clinical
and cost-effectiveness with laparoscopic surgery are required to assess the
possible role of this technology in colorectal surgery, since that an increased
incidence of colorectal cancer is expected in the next decade.
P023: RE-LEARNING CURVE IN ROBOTIC COLORECTAL SURGERY
WITH A NEW DA VINCI SI HD G Spinoglio, MD, R Quarati, MD, F
Priora, MD, LM Lenti, PHD, F Ravazzoni, PHD, V Maglione, MD Division
of Oncologic General Surgery, ASO "SS Antonio e Biagio e Cesare Arrigo",
Alessandria , Italy
Aim: Our robotic experience began in November 2005. The activity stopped in
December 2007 after 216 surgical procedures. In March 2010 we obtained a
new Da Vinci Si HD. A re-learning curve, started with colorectal procedures,
was necessary. We compared recent results of colorectal procedures to previous
experience.
Methods: Proctocolectomy: 24 (1st series) - 25 (2nd series); Miles: 2 (1st series) –
5 (2nd series); Left colectomy: 22 (1st series) – 14 (2nd series); Right colectomy
25 (1st series) – 11 (2nd series).
Results: Proctocolectomy: mean operative time (T): 444 vs 413 min. (p=0.263),
conversion rate (CR): 16% vs 12% (p=0.641); complications I-II grade: 7 vs
1 (p=0.008), complications III-IV grade: 2 vs 4 (p=0.413).No differences
were observed in the patients’ features of two series. Left colectomy: T =
345/321 min (p=0.436), CR 14% vs 0 (p=0.149); complications I-II grade: 2
vs 0 (p=0.149), complications III-IV grade: 1 vs 1 (p=0.209). No differences
wereobserved in the patients’ features of two series. Right colectomy: T =
316/266 min (p=0.106), CR 4% vs 0 (p=0.501); complications I-II grade: 7 vs
1 (p=0.209), complications III-IV grade: 0 vs 1 (p=0.501). No differences were
observed in the patients’ features of two series.
Conclusions: We observed a progressive trend to a reduced operative time and a
similar rate of conversions and complications between the two series for all the
procedures. The re-learning curve was faster probably because of the previously
gained expertise and the new enabling features of Da Vinci Si HD System.
P024: COMPARISON OF ROBOTICALLY PERFORMED AND
TRADITIONAL LAPAROSCOPIC COLORECTAL SURGERY. HC Pappis,
MD PhD FACS, N Pararas, MD PhD, D Kotsakou, MD ’Hygeia’ Hospital,
Athens, Greece
Introduction: The use of the Da Vinci Robotic System is postulated to have
better surgical results by allowing improved instrument manipulation, three-
dimensional vision, enhanced precision and surgeon’s comfort. The authors’
experience performing robot-assisted laparoscopic colorectal surgery is
reported.
Methods & Procedures: We compare standard laparoscopic procedures with robot-
assisted colorectal surgery, including benign and malignant diseases. Between
September 2008 and December 2010, 11 robotic colorectal procedures have been
performed (6 low anterior resections, 5 left colectomies and 1 right colectomy).
One case has been converted to classic laparoscopic procedure and no major
complication has been noted to this group of patients. We matched these cases
with laparoscopic ones, choosing the age/gender, and similar ASA score.
Results: We report the comparison concerning the operative time, blood loss,
length of stay, hospital costs and surgery related complications. Robot-assisted
laparoscopic colectomy is a feasible and safe procedure. Although three-
dimensional vision and dexterity are facilitated, operative time is moderately
increased and the overall additional expense of robotics is of concern. Moreover,
the conclusions are not the same for all kind of procedures.
www.mirasurgery.org
Conclusion. Robot-assisted laparoscopic colorectal surgery requires further
evaluation to establish clinical and financial benefits before introduction to
routine practice.
P025: ROBOT IN TREATING WELL-SELECTED LEFT-SIDED
PANCREATIC CANCER- ROBOTIC ANTERIOR RAMPS Chang Moo Kang
Yonsei University College of Medicine
Background: Laparoscopic distal pancreatectomy with splenectomy is regarded
as a safe and effective treatment for benign and borderline malignant pancreatic
lesions. However, its application for left-sided pancreatic ductal adenocarcinoma
(PDAC) is still debating.
Materials & Methods: Relatively pancreas-confined tumor with intact fascia layer
between pancreas and left adrenal gland/ kidney is thought to be potential
indication for minimally invasive approach in treating left sided pancreatic
cancer. Four patients with pancreatic cancer were selected for robotic RAMPS.
Four robotic arms were used in supine position with the patient’s head- and
left-side elevated. Pancreatic dissection from right to left was performed
after division of pancreatic neck portion. Lymph nodes around common
hepatic artery and celiac axis were dissected during this procedure. The
clinicopathologic characteristics and perioperative surgical outcome including
interim oncologic outcome were analyzed.
Result: Three patients were male and one is female with median age, 63 years
old (53-72 years). Three were reported to be adenocarcinoma of the pancreas,
and one was invasive intraductal papillary mucin-producing carcinoma. Median
operation time was 390min (350-720 min) and median intraoperative bleeding
was 475ml (350-700 min). Pancreatic resection margins including posterior
tangential margins were not involved by malignant cells. Median number
of retrieved LNs was 8.5 (2-23). Median length of hospital stay was 7 days
(4-11 days). All patients receive postoperative adjuvant chemotherapy within
one month after surgery. During median follow up period of 24 months, no
recurrence and no cancer-specific mortality were noted.
Conclusion: Robotic modified anterior RAMPS is technically feasible and safe
for margin negative resection in well-selected left sided pancreatic cancer. The
oncologic feasibility still remains to be determined.
P026: TRANSHIATAL VERSUS THORACOSCOPIC ROBOTIC
ESOPHAGEAL DISSECTION Carlos Loureiro González, Ismael Díez del
Val, title, Inmaculada Cruz González, Saioa Leturio Fernández, Sandra Ruiz
Carballo, José Esteban Bilbao Axpe, José Ramón Cotano Urrutikoetxea, Jaime
Jesús Méndez Martín Gastroesophageal Surgery Unit, Hospital Basurto, Bilbao
Robotic surgery may facilitate some difficult steps during esophageal surgery.
We usually start the operation depending on the location of the primary tumor,
i.e., laparoscopicaly for lesions at the distal third or esophagogastric union, or
thoracoscopicaly for tumors situated at the middle third.
This allows an accurate evaluation of resectability and concomitant locoregional
metastases.
The first part of the video shows progression from the stomach up to above
the carina during the transhiatal technique. After passing a Penrose drain for
traction around gastroesophageal union and performing the Pinotti maneuver,
pericardium, parietal pleurae and inferior pulmonary veins are identified and
the esophagus carefully dissected.
Then, thoracoscopic approach with the patient at the prone position is showed
for resection of a middle-third tumor. After selective intubation, the lung
collapse is helped by mild CO2 insufflation up to 6mmHg. Acygos vein is
stapled (30mm-2.0 grey cartridge) through the assistant trocar. Dissection
progresses after identification of aorta at the upper part of the operating field,
and pericardium, pulmonary veins and membranous part of both bronchi and
trachea behind. Once the whole esophagus has been freed, a pleural drain is
placed and the thoracic phase concluded.
Whereas the thoracoscopic robotic approach reproduces faithfully the classical
thoracoscopic technique, robotic transhiatal esophagectomy represents one of the
main contributions of robotics to esophageal surgery, improving dissection and
avoiding blind steps. Most patients recover without necessity of pleural drain.
41
Poster Abstracts
P027: AN INTERNATIONAL SURVEY TO EXAMINE ATTITUDES
TOWARDS ROBOTIC SURGERY Sheraz R Markar, MRCS MA MBBChir,
Ivana Kolic, MBBS, Alan P Karthikesalingam, MRCS MA MBBChir, Oliver J
Wagner, MD, Monika E Hagen, MD University College London Hospital
Introduction: The field of robotic surgery is rapidly advancing both in terms of the
surgical procedures performed and the potential applications of this technology.
The boundaries in this field are increasing being pushed, with the advent of
tele-surgery, remote-surgery and internal robots. With such rapidly changing
technology it becomes increasingly important to examine the views of the public
regarding this technology. This survey study represents the first attempt to
evaluate the opinions of the public regarding a number of issues in robotic surgery.
Methods: A web-based survey study was constructed using a web-based
programme ’Kwiksurveys’. This survey was then advertised and distributed over
the Internet to gain responders from a wide range of socio-economic groups and
in a number of countries. Responses were collected over a 3-month period.
Results: 153 participants took part in this survey study. The mean age of
participants was 35.8 ± 3.4 yrs. The male: female ratio was 77:74 (51% vs.
49%). 74% (113) of participants had previously heard of robotic surgery. The
most important factor to participants when choosing their type of surgery was
post-operative complications (56%) followed by length of post-operative recovery
(26%), Operating surgeon’s preference (15%) and Post-operative pain (3%). The
majority of participants (32%) were totally comfortable, with the current version
of robotic surgery during which a surgeon in the same room controls instruments
inside the patient. 54% of participants reported they would only find it acceptable
if the operating surgeon controlling the robotic instruments was in the operating
room. Furthermore only 10% of participants reported it would be acceptable for
the operating surgeon to be in another district or country whilst controlling the
robotic instruments. 59% of patients completely disagreed with the statement, ’I
would agree to be operated on by a surgeon from another country controlling the
robotic instruments by tele-surgery if it was cheaper’, with only 9% of participants
completely agreeing with the statement. 68% of responders reported they would
be very uncomfortable with the idea of not seeing the operating surgeon in person
before or after surgery. When asked, ’how do you feel about intelligent robotics
that perform your surgery without direct control by a surgeon by being pre-
programmed’, 68% of responders reported they would be very uncomfortable.
45% of participants reported they would consider idea of an internal robot
operating internally with little or no external scarring. 56% of responders felt
further research in the field of robotic surgery as very important.
Conclusion: This survey study has demonstrated that currently the public appear
to be comfortable with the current version of robotic surgery, with the operating
surgeon in the same room as the patient. However the idea of tele-surgery with the
surgeon in another country to the patient, appears to be less well accepted. The
results of this survey study show that even with the technical advances in robotic
surgery, patients will still want to have contact with their operating surgeon.
P028: ROBOTIC HELLER MYOTOMY: LEARNING CURVE,
ADVANTAGES, AND LIMITATIONS Eric C Nelson, MD, Mohamed R Ali,
MD, William Smith, BS, Tamas J Vidovszky, MD University of California,
Davis Medical Center, Sacramento, CA
Background: The surgical treatment of achalasia has well-established outcomes
superior to medical management, and laparoscopic surgery minimizes the
morbidity of the intervention. We investigated the addition of the da Vinci
robotic system to the laparoscopic Heller myotomy and examined the learning
curve, advantages and limitation of the procedure.
Material & Methods: We reviewed all (n = 29) robotic Heller myotomies
performed between February 2006 and July 2010. We recorded operative time,
setup time of robotics instrumentation, conversion to laparoscopic or open
surgery and complications of the procedure.
Results: 100% of the Heller myotomies were completed robotically, although
additional procedures during the same anesthesia were performed purely
laparoscopically. We did not experience any significant complications directly
related to robotic surgery. The mean total operating time +/- standard deviation
was 219 +/- 66 min. When the six procedures which involved additional hernia
repairs or pyloromyotomies are excluded, the mean operating time was 207
+/- 65. The mean setup time for robotics (from incision until robot was in
place, including draping the robot) was 75 +/- 34 min. However, the setup time
significantly improved as we gained more experience: from 102 +/- 36 min (first
42
10 cases) to 55 +/- 19 min (last 10 cases). The mean robotic time was 90 +/- 39
min. We observed almost no change in robotic procedure time throughout the
study period. The overall operative time decreased significantly from an average
of 250 min during the first 10 procedures to 164 min during the last 10. This
corresponds to a learning curve of 85% during our initial experience.
Conclusions: Robotic Heller myotomy offers significant advantages such as three-
dimensional view, easier instrument manipulations and possibility of remote
site surgery. We observed some shortcomings of robotic surgery such as need
for larger and additional ports, and need for undocking the machine to perform
additional procedures or change the patient position. Decreases in set-up time
and docking were primarily responsible for our initial learning curve.
P029: INITIAL EXPERIENCES OF ROBOT-ASSISTED POSTERIOR
RETROPERITONEOSCOPIC ADRENALECTOMY (PRA); SINGLE PORT
ACCESS Sang-Wook Kang, MD, Haeng Rang Ryu, MD, Jong Ju Jeong, MD,
Woong Youn Chung, MD Department of Surgery, Yonsei University College of
Medicine
Introduction : Recent advances in the technologic and surgical instrument fields
have resulted in the developments of robotic adrenal surgery. PRA has several
superior benefits comparing to the others in terms of direct and short access
to the target organ, no trespass and irritation of intraperitoneal space, no need
of retracting adjacent organs, and safety and ease for learning this method.
Recently, we have experienced several cases of robot-assisted PRA using
single-port access for small adrenal tumor. In this study, detailed methods and
preliminary results will be introduced.
Patients & Method: From March. 2010 to July 2010, 5 patients have undergone
robot-assisted PRA using single ports access. The patient lies as prone, jack-
knife position with hip joints bending at a right angle. A 3 cm-sized transverse
skin incision was made just below the lowest tip of the 12th rib, and the
Glove port® (NELIS, Kyung-gi, Korea) was applied to the skin incision and
maintained pneumoretroperitoneum. Small vessels were ligated with Harmonic
Scalpel and central vein of adrenal gland was ligated with endo-clips. The
clinico-pathologic data of the patients were analyzed retrospectively.
Results: The mean age of the patients was 56.6±8.7 and 2 women and 3 men
were included. Right and left side approaches were performed in 1 and 4
patients, respectively. All the cases were primary aldosteronism. The mean
size of tumor was 1.48±0.28cm. Mean operative time was 159.4±57.6 minutes
(range 103 to 245) and mean estimated blood loss was 46.0±63.8. Average
time to oral intake and postoperative hospital stay were 0.6 and 4.0 days,
respectively. The mean numbers of analgesics use for pain control was 1.8±0.8.
There was no conversion to open surgery and postoperative complications.
Conclusion: Our initial experiences of robot-assisted single port retroperitoneoscopic
adrenalectomy did much to assure us of its safety and feasibility. We suggest that
robot assisted single port retroperitoneoscopic adrenalectomy can be viewed as a
useful surgical option for the treatment of adrenal pathologies.
P030: ADVANTAGES OF ROBOTIC GASTRECTOMY IN
EXTRAPERIGASTRIC LYMPHADENECTOMY COMPARED TO
LAPAROSCOPIC GASTRECTOMY Kazutaka Obama, MD PhD, Woo Jin
Hyung, MD PhD, Yanghee Woo, MD, Kyung Ho Pak, MD, Hyoung-Il Kim,
MD PhD, Sung Hoon Noh, MD PhD Department of Surgery, Yonsei University
College of Medicine
Introduction: Although robotic surgery is gaining popularity, robotic gastrectomy
(RG) for gastric cancer has not widely accepted yet because advantages of RG
still remains unclear. To evaluate the effect of robotic assistance, we focused
on the D2 lymphadenectomy during distal gastrectomy by robotic assistance
in gastric cancer surgery. We investigated whether there are any advantages of
robotic surgery in lymphadenectomy over conventional laparoscopic surgery.
Methods & Procedures: From May 2003 to December 2009, 316 robotic and
713 laparoscopic gastrectomies were performed for gastric cancer patients
in Yonsei University Severance Hospital. Among these, we performed distal
subtotal gastrectomy with D2 lymphadenectomy for 97 patients by robotic
and for 258 patients by laparoscopic. We retrospectively compared patients’
characteristics, retrieved number of lymph nodes (LN) at each LN station,
operative outcomes and postoperative complications between robotic distal
gastrectomy (RDG) group and laparoscopic distal gastrectomy (LDG) group
using prospectively maintained database.
6 TH ANNUAL MIRA CONGRESS May 11-13, 2011
 Results: With regard to the patients’ characteristics, there was no significant
difference of gender, BMI, histology, tumor location, tumor size and depth
of invasion, between the two groups. However, RDG group was significantly
younger than LDG group (53.1±13.0 and 58.5±12.0, respectively) and nodal
involvement differed significantly between the two groups; positivity of LN
metastasis of RDG group was higher than LDG group (32.0% amd 17.1%,
respectively). Regarding retrieved number of suprapancreatic LNs (#7, 8, 9,
11p, 12a), significantly more LNs were dissected in RDG (15.7±7.4) than in
LDG (13.6±7.3) (p=0.016). When we analyzed the patients who received
D2+#14v LN dissection (77 patients in RDG, 171 in LDG), retrieved number
of extraperigastric LNs (suprapancreatic LNs + #14v) was also significantly
more in RDG (17.7±8.0) compared to LDG (15.6±7.7) (p=0.045). Among
extraperigastric LN stations, retrieved numbers of LNs in RDG were significantly
more in station No.9 and No.11p (4.6±3.4 and 2.5±2.8) than those in LDG
(3.6±3.3 and 1.8±2.4) (p=0.018 and 0.014, respectively). Retrieved number of
LNs in station No.12a also differed between RDG (2.0±2.3) and LDG (1.5±2.2),
although this difference was marginal (p=0.067). Regarding operative outcomes,
mean operative time in RDG (217min) was 46min longer than that in LDG
(171min) (p<0.001), whereas mean blood loss was significantly less in RDG
(56ml) compared to LDG (131ml) (p<0.001). Occurrence rate of postoperative
complications did not differ between the two groups.
Conclusions: These data suggest that robotic assiatnce may help surgeons perform
more complete D2 lymphadenectomy than laparoscopic surgery during
gastrectomy for gastric cancer with same safety. Further studies are required
to clarify whether this advantage of robotic surgery affects long term outcomes
(local recurrence and survival) of gastric cancer patients.
P031: ROBOTIC REDO FOR FAILED LAPAROSCOPIC NISSEN
FUNDOPLICATION Ismael Díez del Val, Carlos Loureiro González, Sandra
Ruiz Carballo, Saioa Leturio Fernández, Inmaculada Cruz González, José
Esteban Bilbao Axpe, Jaime Jesús Méndez Martín, Ángel Gómez Palacios
Gastroesophageal Surgery Unit, Hospital de Basurto, Bilbao, Spain
We present a case of failed laparoscopic Nissen in a young woman operated on
18 months before for gastroesophageal reflux disease (GERD). The operation
consisted on acalibratedcrura closure anddivision of short gastric vessels, with
fundoplication not sutured to the esophagus.
She presented progressive dysphagia. The esophagogram showed a slipped
Nissen with the fundoplication lying down on the gastric body.
The robotic technique starts by freeing adhesions from previous surgery. Once
the crura and the fundoplication are identified, we pass a Penrose drain around
distal esophagus for traction. Greater curvature and His angle are exposed
and fundoplication completely taken down. Finally, after guaranteeing the
intrabdominal location of the distal part of the esophagus, a new short floppy
Nissen is performed, adequately secured to the esophagus.
Robotic surgery enhances image stability, allows fine dissection and
identification of structures. We consider that this approach may become the gold
standard for reoperations in this anatomic region.
P032: TOTALLY ROBOTIC SUBTOTAL GASTRECTOMY FOR CANCER
Carlos Loureiro González, Ismael Díez del Val, Inmaculada Cruz González,
Saioa Leturio Fernández, Sandra Ruiz Carballo, José Esteban Bilbao Axpe,
Jaime Jesús Méndez Martín Gastroesophageal Surgery Unit, Hospital de
Basurto, Bilbao
Robot-assisted gastrectomy has been demonstrated feasible and safe in a few
published reports. After several years’ experience with open and laparoscopic
gastrectomy, we have started performing totally robotic Roux-en Y gastrectomy,
that reproduces quite faithfully the previous technique, except that clips and
staplers are introduced by the assistant. The patient is placed in the reverse
Trendelenburg position, with the first assistant between the legs. The surgeon’s
left hand’s instrument passes through an 8mm-robotic trocar telescoped into
a 12mm’s one, to fire staplers when needed. Another 12mm trocar is placed
on the left midclavicular line for assistant and, at the end of the operation, to
remove surgical specimen. After freeing the great omentum, right gastroepiploic
vessels are divided at their origin, including group 6 nodes, and the duodenum
transected. Then, right gastric artery is clipped and lymphadenectomy performed
along the common hepatic artery to the celiac axis and, after ligating the left
gastric vessels, continued up to the right diaphragmatic crus. The stomach is
divided with several blue-cartridge linear staplers, and a tension-free hand-sewn
www.mirasurgery.org
gastrojejunostomy performed, once the jejunum has been sectioned about 40cm
distal to the Treitz angle. Entero-enterostomy can be performed mechanically
or through the 4 to 5cm incision used to extract the specimen. Totally robotic
subtotal gastrectomy is feasible and safe. Its main advantages seem to be a more
accurate lymphadenectomy and easier hand-sewn anastomoses. The future will say
about its applicability in large series.
P033: FROM LAPAROSCOPIC TO ROBOTIC GASTROESOPHAGEAL
SURGERY Ismael Díez del Val, Carlos Loureiro González, Sandra Ruiz
Carballo, Saioa Leturio Fernández, Inmaculada Cruz González, José
Esteban Bilbao Axpe, Jaime Jesús Méndez Martín, Ángel Gómez Palacios
Gastroesophageal Surgery Unit, Hospital de Basurto, Bilbao
Objective of the Study: To evaluate the feasibility and safety of robotic
gastroesophageal surgery in a surgical unit with experience in the same
procedures by open or laparoscopic approach.
Methods & Procedures. From September 2009 to November 2010, 32 patients
(19 men and 13 women) with different gastroesophageal diseases underwent
laparoscopic surgery with a Da Vinci robotic system at our Institution. Mean
age was 60.5 years. First of all, we performed 6 anti-reflux surgery cases to
advance in the learning curve. Progressively, all kind of pathologies currently
treated at our Unit were submitted to robotic surgery: 7 paraesophageal hernia
repairs, 1 redo, 3 cases of achalasia, 9 esophageal neoplasms (6 transhiatal and 3
by thoracoscopy), 2 gastric cancers, 1 middle-third leiomyoma, 1 morbid obesity
and 2 gastric stromal tumors (GIST).
Results: Mean hospital stay was 14.1 days for patients diagnosed of esophageal
carcinoma and 4.7 for the rest of the series. All the procedures but three were
completed endoscopically. Two elective conversions to open surgery were due
to difficult posterior gastric dissection at the end of a transhiatal esophagectomy
in one case and to the impossibility to reduce an intrathoracic gastric volvulus in
another one; the third case corresponds to an unresectable squamous carcinoma
whose preoperative pathologic diagnosis was leiomyoma. We had two major
complications requiring reoperation: one leak in the stapled line of the gastric
tube after a transhiatal esophagectomy and one case of intrathoracic gastric
migration after dissection of the greater curvature and lower esophagus in a case
of esophageal carcinoma that was stopped due to carcinomatosis implants on the
anterior aspect of the pancreas. One cervical fistula was treated conservatively.
All the complications were observed in patients suffering from esophageal
carcinoma. Mortality was nil.
Conclusions: Robotic gastroesophageal surgery is feasible and safe. Its main
contribution seems to be mediastinal dissection, either for giant hernias,
myotomy or transhiatal esophagectomy. The observed complications were not
directly related to the robotics itself, but rather to the complexity of the patient
or the pathology. Experience in open and laparoscopic surgery may contribute to
reduce the learning curve.
P034: ROBOT-ASSISTED TRANSHIATAL ESOPHAGECTOMY Carlos
Loureiro González, Ismael Díez del Val, José Esteban Bilbao Axpe, José Ramón
Cotano Urrutikoetxea, Jaime Jesús Méndez Martín Gastroesophageal Surgery
unit, Hospital de Basurto, Bilbao
Introduction. Minimally invasive surgery is a quite new approach for the
treatment of esophageal cancer. Thoracoscopic approach in the prone position
could be considered the gold standard of treatment because it allows a precise
dissection of the thoracic esophagus avoiding the morbidity of the thoracotomy.
Nevertheless, in lower-third esophageal carcinoma, especially adenocarcinoma,
the possibility of unexpected unresectable disease or peritoneal metastases
makes it advisable to carry out an initial laparoscopic approach. Without any
change in the position of the patient, transhiatal esophagectomy is an attractive
but complex option that may be facilitated by robotic surgery. The aim of this
presentation is to evaluate the contribution of robotics to the surgical treatment
of lower-third esophageal carcinoma.
Methods & Procedures. From January to November 2010, 5 patients between 51
and 70 years old, all males, underwent a robotic transhiatal esophagectomy
for cancer at our Institution, 6 to 8 weeks after completing neoadjuvant
radiochemotherapy. Three 8mm-robotic trocars are used, one of them for liver
and pericardial retraction. After hiatal dissection, a Penrose drain is passed
for traction, followed by progression up to above the carina. At the level of the
inferior pulmonary veins, the 30o camera is changed to 0o, to improve anterior
dissection. Direct branches from the aorta are sealed with harmonic o bipolar
43
Poster Abstracts
cautery. Eventual openings of the pleurae are treated by decreasing abdominal
pressure to 10mm Hg. Because no major contamination of the pleural space
occurs, no thoracic drains have been placed. Although we have performed
Kocher maneuver, gastric tube stapling or pyloroplasty by robotic surgery,
we prefer doing it by conventional laparoscopy, after undocking the Da Vinci
system. The surgical specimen is removed through a left lateral cervicotomy,
and a hand-sewn anastomosis carried out.
Results. Four procedures were completed laparoscopicaly. One elective
conversion was needed due to difficult posterior gastric dissection, once
the esophagus had been completely freed. We had a leak at the staple line
of the gastric tube requiring reoperation and a cervical fistula managed in a
conservative way, but none of these events were directly related to the robotic
approach. The mean number of lymph nodes harvested was 12 per patient
(range: 6 to 19). The mean hospital stay was 17,4 days (10-32). There was no
mortality in the series.
Conclusions. During transhiatal esophagectomy, the surgeon has to work in a
narrow deep operating field, where robotic surgery has several advantages:
image stability, instruments length and degrees of freedom, precision of
movements, improved dexterity. Although this technique is complex and
complications frequent, we consider that it represents one of the main
applications of robotic surgery.
P035: ROBOT-ASSISTED THYROIDECTOMY BY TRANSAXILLARY
APPROACH Nicolae Constantea, Profesor PhD MD, Dan Axente, MD 5th
Surgical Clinic, Cluj-Napoca County Hospital, Romania
Background: Over the past 2 decades many endoscopic thyroidectomy
procedures have been developed trying to minimize visible scarring and to
reduce postoperative pain. Recently robotic technology has been also applied
to thyroid surgery using a gasless transaxillary approach. Our objective was to
evaluate the technical feasibility, intraoperative safety and efficacy of this new
robotic procedure.
Methods: We used the da Vinci SI Surgical Robotic System and we performed 9
total unilateral lobectomy via transaxillary approach without gas insufflation.
All 9 patients were diagnosed with unilateral thyroid nodules. For each patient,
we analyzed the clinical characteristics, tumor size, pathologic type, operative
time, amount of drainage, duration of hospital stay, postoperative complications,
postoperative neck and anterior chest pain, and cosmetic satisfaction.
Results All operations were performed successfully without any need for
conventional open conversion. The mean overall operation time was 170 min.
respectively 90 min. console time. The mean tumor size was 3.8 cm. There was
one temporal brachial plexus neuropraxia and one wound seroma. There were
no malignant thyroid lesions.
Conclusions Robotic thyroidectomy by gasless transaxillary method is feasible,
safe, and provided good outcomes. Robotic technology overcame some technical
limitations associated with conventional endoscopy.
P036: FEASIBILITY AND SAFETY OF ROBOT ASSISTED-ENDOSCOPIC
THYROIDECTOMY-SYSTEMATIC REVIEW Eugenia Yiannakopoulou, MD
Msc PhD, Nikolaos Nikiteas, MD PhD, Christos Tsigris, MD PhD Faculty of
Health and Caring Professions Technological Educational Institute of Athens,
2nd Department of Propedeutic Surgery School of Medinice NKUA, 1st
Department of Surgery School of Medicine NKUA
Background: Robotic thyroidectomy is a new approach to thyroid surgery, that
offers the benefit of eliminating the anterior neck incision utilized in traditional
approaches. Additional advantages include three dimensional working field,
a magnified view, tremor filtering system, multiarticulated instruments.
However, no level I evidence exists to strongly support the robotic approach to
thyroid surgery. This study is a systematic review that aims to summarize data
on the feasibility and safety of robotic thyroidectomy.
Methods: Pubmed, Scopus, Google Scholar were searched with the appropriate
search terms up to and including December 2010. Clinical trials randomized or
not, retrospective studies, case series, case reports, cadaver and experimental
studies were all included. Papers published only in abstract form or presented
in congresses were excluded. Extracted data included type of study, number
of patients, indication of thyroidectomy, surgical technique applied, operative
time, number of lymph nodes extracted in case of dissection, final pathology,
conversion rate, complications.
44
Results: Twenty eight papers were identified including multiple publications
of the same series. There were no randomized clinical trials. Most of the
trials were retrospective studies, case series and case reports, that described
the author’s experience in robotic thyroidectomy. One small clinical trial
compared robot assisted endoscopic with open thyroidectomy and one
small retrospective study compared conventional endoscopic with robotic
thyroidectomy. Patient selection criteria varied among different studies. Thus,
robot assisted thyroidectomy was applied for predominant benign nodules <
4 cm or < 5 cm and for malignant or potentially malignant nodules < 2 or <
4 cm at its largest diameter. The thyroid gland was approached laterally using
the gasless trans-axillary approach, unilateral axillary- breast approach, the
bilateral axillary-breast approach. Direct transoral approach to the thyroid
gland was applied in two cadavers. Robot assisted operations performed
included total thyroidectomy, lobectomy, total thyroidectomy with modified
lateral neck dissection, total thyroidectomy with central node dissection,
subtotal thyroidectomy with central node dissection. Indications included well
differentiated thyroid carcinoma with lateral node metastasis, multinodular
goiter with predominant nodule, indeterminate nodules. Operative time
ranged from 67 to 279 min. Approximately 25% of the time was spent
docking and setting the robot machine. Complications included transient
recurrent laryngeal nerve palsy, transient hypocalcaemia, permanent ipsilateral
recurrent laryngeal nerve palsy, permanent hypoparathyroidism, transient
hoarseness, Horner’s syndrome, postoperative muscle flap hemorrhage, tracheal
injury, wound seroma, wound erythema, brachial plexus neuropraxia due to
traction injury. A drawback of robotic thyroidectomy observed in a number
of studies was a remnant little thyroid tissue (>1-2 gr) at Berry’s ligament or
the upper pole of the contralateral side due to an insufficient surgical angle.
Concerning comparison with open or conventional endoscopic thyroidectomy,
early operative outcomes seem satisfactory in terms of hospital stay, pain,
complications and degree of complete resection.
Conclusion: Limited available data suggest that robot assisted thyroidectomy is
feasible and safe. However, drawbacks exist, i.e. the extent of trauma seems
larger. Large multicenter studies are needed to evaluate patient selection
criteria, postoperative morbidity due to laryngeal nerve injury and to
hypoparathyroidism, long term oncologic and cosmetic results.
P037: FEASIBILITY AND SAFETY OF ROBOT ASSISTED-
ADRENALECTOMY -SYSTEMATIC REVIEW Eugenia Yiannakopoulou, MD
Msc PhD, Nikolaos Nikiteas, MD PhD, Christos Tsigris, MD PhD Faculty of
Health and Caring Professions Technological Educational Institute of Athens,
2nd Department of Propedeutic Surgery School of Medinice NKUA, 1st
Department of Surgery School of Medicine NKUA
Background: The first robotic adrenalectomy in humans was reported in 2001
by Horgan and Vanuno. The robotic approach is an interesting option for
overcoming the limitations of laparoscopic adrenalectomy as it offers three
dimensional view and faster learning curve. However, evidence on the role of
robotic adremalectomy is limited. This study is a systematic review that aims to
summarize data on the feasibility and safety of robot-assisted adrenalectomy.
Methods: Pubmed, Scopus, Google Scholar were searched with the appropriate
search terms up to and including December 2010. Clinical trials randomized or
not, retrospective studies, case series, case reports, cadaver and experimental
studies were all included. Papers published only in abstract form or presented
in congresses were excluded. Extracted data included type of study, number
of patients, indication of adrenalectomy, surgical technique applied, operative
time, final pathology, conversion rate, complications.
Results: Thirty six trials were identified and they were obtained in full text.
Seven publications were previous double or multiple publications of smaller
series and therefore were excluded. Most of the trials were retrospective studies,
case series and case reports, that described the author’s experience in robot
assisted adrenalectomy. One randomized clinical trial (RCT) was identified, that
compared robot-assisted with laparoscopic adrenalectomy. Two experimental
studies were also included. According to available data, two hundred eighty
two patients have been submitted to robot assisted adrenalectomy. Operations
performed included left sided robot-assisted transperitoneal adrenalectomy,
right sided robot-assisted transperitoneal adrenalectomy, bilateral robot-assisted
adrenalectomy, robotic posterior retroperitoneal adrenalectomy, robotic partial
adrenalectomy. Indications included glucocorticoid secreting adenoma, adrenal
hyperplasia (one bilateral), incidentaloma, cortical adenomas, multilocular
6 TH ANNUAL MIRA CONGRESS May 11-13, 2011
 haemorrhagic cysts, pheochromocytoma, aldosteronoma, myelolipoma,
non functioning adenomas, ganglioneuroma, lymphangioma, adrenocortical
carcinoma, metastatic lesions (colorectal cancer, adrenal carcinoma). Robotic
resection of pheochromocytoma in the second trimester of pregnancy has also
been reported. A limited number of complications were reported. Intra-operative
complications included intraoperative bleeding in three patients, due to injury to
the spleen in one patient with 6 cm left pheochromocytoma, from right renal vein
injury in an obese patient with a 2 cm right incidentalloma, and from the right
adrenal vein in an obese patient with Cushing’s adenoma, intraoperative capsular
tear and in two patients with large phaeochromocytomas (6 and 7,5 cm). Post-
operative complications included one death in a patient with pheochromocytoma
due to fatal arrhythmia following myocardial infarct, diarrhea due to Clostridium
difficile, pneumonia, urinary tract infection, wound trauma. The rate of
conversion from robotic assisted to laparoscopic or open adrenalectomy ranges
from 0 to 5%. However, in the RCT, that included ten patients in each group,
the authors reported 40% conversion rate to laparoscopic adrenalectomy due to
malpositioning of trocars.
Conclusion: Limited available data suggest that robot assisted adrenalectomy is
feasible and safe. However, the advantages of robotic adrenalectomy for the
patients have not been defined yet, although it seems that robotic adrenalectomy
confers advantages for obese patients and for patients with large tumors.
Randomized clinical trials are needed to compare robotic assisted with
conventional adrenalectomy and to evaluate the safety of robotic adrenalectomy.
P038: A PROSPECTIVE COMPARISON OF THE VOICE QUALITY AFTER
ROBOTIC VERSUS CONVENTIONAL OPEN THYROIDECTOMY FOR
THE PAPILLARY THYROID CANCER 2Jong Ho Yoon, 3Chi Young Lim,
1Kyu Hyung Kim, 1Jae Hyun Park, 1Sohee Lee, 1Haeng Rang Ryu, 1Sang-Wook
Kang, 1Jong Ju Jeong, 1Kee-Hyun Nam, 1Woong Youn Chung, 1Cheong Soo
Park 1Yonsei University College of Medicine,2Asan Medical Center, University
of Ulsan College of Medicine, 3National Health Insurance Corporation Ilsan
Hospital
Purpose: The aim of this study was to evaluate and compare the voice quality after the
robotic and conventional open thyroidectomy for papillary thyroid cancer (PTC).
Patients & Methods: Among total of 72 patients with PTC, 35 and 37 patients
underwent a robotic thyroidectomy using a gasless, transaxillary approach (the
robotic group; RG) and a conventional open thyroidectomy (the conventional open
group; OG), respectively. To evaluate the voice quality, we performed objective
computerized acoustic voice analysis (CAVA) and subjective scaled evaluation
of the voice (SSEV) including Korean voice handicap index (KVHI) and Korean
voice-related quality of life (KVRQOL). The CAVA was done preoperatively and
3 months after thyroidectomy. The SSEV was done preoperatively, and 1 week
and 3 months after thyroidectomy. Two groups were compared in terms of pre-
and postoperative objective CAVA and SSEV. The CAVA was analyzed with 5
parameters including the mean fundamental frequency, jitter, shimmer, noise to
harmonic ratio and maximal phonation time.
Results: The mean age of RG was younger than that of the OG, but there was
no significant difference in gender, tumor size, T stage, N stage, and TNM
stage. Preoperative CAVA, KVHI and KVRQOL showed no difference between
the two groups. In the objective CAVA, each parameter was not changed
by thyroidectomy in both groups. Also, the alteration of parameters was
not different between the RG and OG.. In the SSEV, KVHI and KVRQOL
showed lower voice quality postoperatively than preoperatively. But, there
was no statistically significant difference in postoperative scores of KVHI and
KVRQOL between the two groups.
Conclusions: Taking together, there was no major alteration in objective
phonatory parameters of the patients after thyroidectomy, despite that the
patients felt the quality of their voice was low. Also, the voice quality after
thyroidectomy was not different between the two groups.
P039: INTRAOPERATIVE NEUROMONITORING OF THE EXTERNAL
BRANCH OF THE SUPERIOR LARYNGEAL NERVE DURING ROBOTIC
THYROID SURGERY Su-jin Kim, Kyu Eun Lee, Mi Ra Kwon, Kwan Yoon,
Hyuk Jae Choi, Jun Young Choi, Yeo-Kyu Youn Haeundae Paik Hospital, Seoul
National University Hospital, Korea
Background: Changes of the voice caused by injury of the external branch of the
superior laryngeal nerve (EBSLN) during thyroid surgery diminished quality of
life. Therefore, identification and preservation of the EBSLN is important during
www.mirasurgery.org
thyroid surgery. The aim of this study is to evaluate the feasibility and efficacy of
intraoperative neuromonitoring (IONM) of EBSLN in robotic thyroid surgery.
Patients & Methods: We analyzed 42 patients who underwent IONM of the EBSLN
(group 1) and 26 patients who did not undergo IONM of the EBSLN (group
2) during robotic thyroidectomy. Voice assessment was prospectively obtained
by the Voice Handicap Index-10 (VHI-10) questionnaire before, 2-4 weeks,
and 3 months after surgery. The VHI-10 is a valid and reliable tool to assess
the severity of voice handicap quantitatively. The Nerve Integrity Monitor
(NIM Respone 2.0 System, Medtronic Xomed, Jacksonville, FL) was used for
the EBSLN monitoring and EBSLN is stimulated by direct contact with the
modified monopolar probe. The stimulation level was set at 1mA as a starting
point and the event threshold of 100uV; if no signal was elicited, the stimulation
was increased to 2mA. The identification of EBSLNs is confirmed by an audible
acoustic signal or contraction of the cricothyroid muscle.
Results: The recurrent laryngeal nerve was identified with visualized and IONM in
all patients during thyroid surgery. When the patients in group 1 were compared
with patients in group 2 exhibited a significant difference in patients’ self
assessment of voice severity using the VHI-10 before, 2-4 weeks, and 3 months
after surgery (0.47, 3.93, 0.74 [group 1] vs. 0.46, 5.85, 2.31 [group 2], p =
0.0399, repeated measure ANOVA). In group 1, a total of 83 EBSLNs were at risk,
51 EBSLNs (61.4%) were visualized and identified by IONM 24 EBSLNs (28.9%)
were identified by IONM only, and 8 EBSLNs (9.6%) was not identified.
Conclusion: From this study it is suggested that IONM of the EBSLN during
robotic thyroidectomy is a feasible and helpful to preserve voice quality. Future
studies will be required to ascertain the efficacy of IONM of the EBSLN using
objective assessment.
P040: ROBOTIC SURGERY FOR MORBID OBESITY: ROUX-EN-Y
GASTRIC BYPASS, GASTRIC BANDING, SLEEVE GASTRECTOMY
Christina Delimpalta, Archontis Zampogiannis National And Capodistrean
University Of Athens, Medical School And 1st Surgical Clinic, Laikon Hospital,
Athens, Greece
Introduction: In the last decade laparoscopic surgery has become treatment of choice
for a large number of patients with morbid obesity, with good outcomes and few
complications. The advent and gradual implementation of robotic surgery has
initiated studies looking into its possible usage in bariatric surgery with an aim
of even better results and outcomes, as it overcomes many of the laparoscopic
techniques’ limitations: it offers a three-dimensional view, better ergonomics when
dealing with the thick abdominal walls of the morbidly obese and the ability to
perform more manipulations and complex, precise suturing in a small work space.
Methods & Procedures: Review of the current literature concerning use of robotic
technology for gastric bypass, gastric banding and sleeve gastrectomy in
morbidly obese patients and its possible benefits versus standard laparoscopy.
Results: The most common robotically performed bariatric procedure is gastric
bypass. Studies show it is equally efficient with laparoscopic bypass where excess
body weight loss is concerned. Operative times seem to be longer, although the
difference drops as the OR team gets acquainted with the equipment. When robot
docking time is excluded, the actual operation time is shorter and there is even
one large study showing shorter operating times for the overall robotic procedure.
Complication rates are similar to those of traditional laparoscopy (10-24%), but
most studies show a very significant decrease in anastomotic leaks, likely due to
improvement that comes from lack of abdominal wall torque, and the advantages
the 3-D view of the field affords when performing the gastrojejunal anastomosis.
In most series conversion rate from robotic to laparoscopic is < 5%. The reported
mortality rate ranges between 0 and 1.8% with a morbidity of 1-3.1%. The robotic
technique seems to have a lower learning curve of 30-50 cases, in contrast with
the 70-100 of the laparoscopic bypass. The method’s cost-effectiveness has not
been specifically addressed. Elevated costs for the robotic bypass are considered
a given, although many claim that cost differences are largely caused by the
increased OR time rather than increased instrument costs. Gastric banding and
sleeve gastrectomy have been successfully performed robotically, but the relative
simplicity of the operations along with significantly elevated costs and increased
operative times do not show a clear benefit versus the traditional laparoscopic
approach. However, the biggest series show very low morbidity and no mortality
in the robotic groups, and, especially for banding, a greater ease when working in
small areas and patients with BMI > 60, as instruments are thicker and provide
relief to the surgeon.
45
Poster Abstracts
Conclusions: Initial studies show that robotically-assisted bariatric surgery is
feasible, with the same if fewer complications as laparoscopic techniques and
important benefits such as very low rates of anastomotic leaks. Concerns such as
higher costs and longer operating times seem to be both connected to the degree
of the OR team’s experience, and will probably be addressed more extensively
as more and more centers use robots for their patients.
P041: ENDOSCOPIC AND ROBOTIC THYROID SURGERY WITH LATERAL
NECK DISSECTION FOR PAPILLARY THYROID CARCINOMA USING A
BILATERAL AXILLO-BREAST APPROACH June Young Choi, MD, Kyu Eun
Lee, MD PhD, Yeo-Kyu Youn, MD PhD Seoul National University Hospital
Background & Objectives: Conventional open thyroid surgery with lateral neck
dissection for papillary thyroid carcinoma (PTC) requires a long incision and
thus leaves a cosmetically unfavorable scar. We developed the bilateral axillo-
breast approach (BABA) for endoscopic and robotic thyroidectomy and applied
to lateral neck dissection for PTC patients. The aim of this study was to evaluate
completeness and feasibility of each procedure.
Materials & Methods: From June 2004 to May 2009, 27 endoscopic cases, and
from February 2008 and September 2010, 34 robotic cases with PTC and
suspected lateral lymph node metastases were selected. After performing
thyroidectomy and central compartment dissection, ipsilateral lateral neck
dissection was performed using BABA.
Results: Endoscopic and robotic thyroidectomy and lateral neck dissection were
performed successfully in most patients, but 2 robot cases were converted to
open due to bleeding. Mean tumor size were 0.85±0.44cm in endoscopic cases
and 0.84cm±0.43cm in robotic cases (p=0.264). Mean operative time were
181.3±45.4min in endoscopic cases and 177.0±33.7min in robotic cases (p=0.249).
The yields of lymph node were 3.26±1.95 in central and 4.52±3.65 in lateral
compartment in endoscopic cases, 6.59±4.55 and 5.82±4.19 in robotic cases
(p=0.075, p=0.289). Nine patients (33.3%) had central node metastases and 5
patients (18.5%) had lateral node metastases in endoscopic cases, 12 patients (35.3%)
and 6 patients (17.6%) in robotic cases, respectively. (p=0.517, p=0.808) During
and after the operations, no significant blood loss or postoperative complications
occurred and no evidences of residual disease were found at follow-up.
Conclusion: Endoscopic and robotic thyroid surgery with lateral neck dissection using
a BABA has results of similar operative outcomes including good cosmetic outcome
and has low postoperative complications. Therefore it is feasible and safe to apply
these procedures to the PTC patients with suspected lateral lymph node metastases.
P042: ROBOTIC APPROACH FOR ABDOMINAL HERNIAS - A
ROMANIAN EXPERIENCE Sorin Paun, PhD, Roxana Ganescu, MD, M
Beuran, PhD, C Turculet, PhD, F Iordache, PhD, I Negoi, MD, D Surdeanu,
MD Emergency Hospital - Bucharest, Romania
Minimally invasive surgery tries to become the first choice for abdominal walls
defects approach. We strongly believe that the robotic technique provides
several advantages over the classic laparoscopy.
We are presenting our robotic experience concerning this type of pathology: for
the last two years and a half, we did perform 27 robotic procedures with classic
3-arms DaVinci system for abdominal hernias: 14 inguinal hernias (4 recurrent),
6 postoperative ventral hernias, 4 umbilical hernias and 3 epigastric hernias.
We had patient from 23 to 79 years old with hernias from 2 to 10 cm and an
anterior transperitoneal abdominal robotic approach was performed in all cases.
For inguinal hernia the procedure was performed using either 0º or 30º camera
and for postoperative, umbilical or epigastric hernia the choice was for 30º up
camera. Dissection time was between 55 and 195 min with an OR time from
100 to 351 min (including robot preparation) with a minimum of blood lose (0-
30ml) and no complications were recorded. Postoperative hospital stay was from
1 to 5 days. We did also noticed two patients with bilateral inguinal hernias (one
of them with a recurrent inguinal hernia on one side) operated by TAPP fully
robotic technique, one-step procedures (polypropylene mesh repairs on both
sides for both patients). Total operating time was increased for these two cases
but hospitalization time was very low.
Regarding our experience we can say that the robotic instruments offered a very
good technicality for the console surgeon in every case, despite the position of the
hernia or its dimensions. Robotic repair is able to achieve the same results as the
open or laparoscopic surgical procedure while reducing postoperative hospital stay
and no complications.
46
P043: ROBOTIC APPROACH FOR HYDATID HEPATIC CYSTS Sorin Paun,
PhD, Roxana Ganescu, MD, I Negoi, MD, Mihaela Burtea, MD, B Gaspar, PhD,
M Beuran, PhD Emergency Hospital - Bucharest, Romania
Robotic surgery is a controversial approach for a liver hydatidosis disease, as well
as other minimally invasive techniques.
Two patients with hydatid hepatic cysts were operated by robotic approach in
Bucharest Emergency Hospital in the last 8 months - we are highlighting the
benefits of minimally invasive surgery for this type of pathology.
A retrospective analysis for two cases is presented: the first one, a 27 years old
female was diagnosed by the CT scan with 3 very large hydatid cysts located
in II-III, VI-VII and VII-VIII liver segments and a robotic transperitoneal
approach was performed after 2 weeks of Albendazol treatment and all 3
cysts were inactivated, evacuated and Lagrot pericystectomies with cavities
drainages were performed. Total operating time riched almost 5 hours
and postoperative hospital stay noticed 11 days but with no inconvenient
immediate post-op symptomatology. The second case, a 52 years old female,
with one segment VIII hydatid hepatic cyst was operated by robotic approach
– remnant cavity developed after 2 moths a billiary leakage abcess (due to too
soon removal of the drainage tubes) and laparoscopic reintervention for cavity
drainage was necessary.
We are able to say that the treatment of hydatid hepatic cyst is easier to be
performed by robotic surgery if the cyst localization is difficult to be reached by
open or even laparoscopic procedure. Total operating time can be increased but
we think that it is a matter of personal experience of the surgeon. Postoperative
complications for robotic technique are similar to the other approaches.
P044: ROBOTIC ADRENALECTOMY FOR BENIGN AND MALIGNANT
PATHOLOGIES Archontis Zampogiannis, Christina Delimpalta National And
Capodistrean University Of Athens, Medical School And 1st Surgical Clinic,
Laikon Hospital, Athens, Greece
Introduction: Laparoscopic adrenalectomy is the standard method of removing
benign adrenal tumors and some malignant ones. Although significantly more
beneficial for the patient than the open approach, it is a complex operation,
with the two-dimensional view and difficulty in instrument handling and
hand coordination rendering it very demanding for every surgeon. After its
development, robotic technology has been used to perform adrenalectomies
for mostly any underlying pathology, with the hopes of overcoming some of the
aforementioned technical obstacles.
Methods & Procedures: We reviewed published literature concerning robotic
adrenalectomy.
Results: In most studies the robotic procedures were undertaken using
the da Vinci Robotic System, with 5 entry ports for the system and the
service trocars. Compared with the lateral transperitoneal laparoscopic
adrenalectomy, the robotic procedure offers better, three-dimensional
visualization of the adrenal glands and their vasculature (facilitating especially
vain dissection from the vena cava), bigger freedom to move surgical
instruments and elimination of the surgeon’s physical exertion. As a result,
blood loss is cut by about 50%. On the other hand, operative times are still
significantly longer, with the possible exception of cases where patients have
higher BMI and/or large tumors, when the laparoscopic procedure seems
to be more time-consuming. Importantly, it has been noted that OR time
in itself improves after a learning curve of about 20 cases, as the surgeon’s
experience augments. The robotic approach carries a higher morbidity (7-20%
vs 0%) and a conversion rate to laparoscopic or, unusually, to open procedure
(5-7%, 40% in one study). Post-operative complications are rare and the
duration of hospital stay is equal to that of the laparoscopic procedure. Cost,
however, remains an important drawback, amounting to 1,5-3 times that of
laparoscopic or conventional open adrenalectomy. Recently, there have been
case reports of robots used in minimally invasive partial adrenalectomy in
patients with hereditary conditions affecting both glands, as well as in gland
removal because of malignancy. As far as the first scenario is concerned, due
to its special technical aspects, robotic adrenalectomy is probably going to
be extremely useful in similar cases, where sparing the gland is of pivotal
importance for the patient’s well-being.
Conclusion: Robotic adrenalectomy is feasible and has comparable results with
the standard laparoscopic procedure. Preliminary results indicate subjective
advantages -mainly for the surgeon- but have failed to demonstrate superior
6 TH ANNUAL MIRA CONGRESS May 11-13, 2011
 performance after comparison with the laparoscopic approach. Therefore its
implementation is mostly on a trial basis, but it is probable that it will become
more widespread as costs dwindle and surgeons gain more experience with
robotic equipment.
P045: GIST DUODENAL RESECTION AND RECONSTRUCTION IS A
FEASIBLE ROBOTIC PROCEDURE T . P Singh, MD, Eyad Wohaibi, MD,
James Massullo, MD Department of Surgery Albany Medical Center
Duodenal Gastrointestinal Stromal Tumor (GIST) tumors are rarely seen.
Most surgical treatments for this finding require open surgical intervention.
We describe a case of a Duodenal GIST tumor found secondary to GI bleeding.
Work up prior to surgery showed a localized lesion in the 2nd/3rd portion of
the duodenum without metastatic extension. This tumor was safely resected
and duodenal reconstruction via duodeno-jejunostomy was accomplished under
robotic control. The procedural time, blood loss, length of stay and short term
outcomes are similar to those reported for laparoscopic surgery and somewhat
improved compared to open surgery as described in the literature.
This case may be the first reported robotic resection of a Duodenal GIST
tumor. Additionally, Duodenal resection is a viable option for management of
GIST tumors and should be further studied as the benefits of robotic control on
duodenal resection and reconstruction may be seen in future procedures.
P046: COMPARISON OF SUTURING TASKS USING THE DA VINCI
SINGLE-SITE INSTRUMENTS SYSTEM AND LAPAROSCOPIC SINGLE
SITE INSTUMENTS Tamas J Vidovszky, MD, Bernadette Guiroy, MD, Dan
Eisenberg, MD, James Lau, MD, Homero Rivas, MD University of California,
Davis Medical Center, Sacramento, CA; Salinas Memorial Hospital, Salinas,
CA; Stanford School of Medicine, Palo Alto, CA
Background: Single site laparoscopic surgery has been established for
cholecystectomies, appendectomies, nephrectomies, and various other
procedures. One of the most important shortcomings of single site laparoscopic
surgery is the difficulty with triangulation. Laparoscopic suturing is a highly
advanced skill with a steep learning curve. Suturing with single port system
poses significant difficulty, requiring conversion to traditional multiport
laparoscopy or open surgery. We compared laparoscopic single site suturing
with the da Vinci Single-Site Instruments and Accessories (dVSS) system under
clinically simulated conditions.
Material & Methods: Five surgeons with single site laparoscopic and robotic
experience performed suturing tasks utilizing the dVSS system as well as manual
single incision laparoscopic surgery. The suturing tasks were performed on
explanted animal tissue. A 5 cm long longitudinal incision was made on porcine
small bowel. The participant had 20 minutes to complete a running suture
to close the opening. Following the closure a leak test was performed. Each
participant had performed two separate suturing using single site laparoscopic
suturing with instruments of their choice, and two separate suturing using the
dVSS system. Beside the participant demographics, the time to completion of
the task was measured and leak rate was evaluated.
Results: The 5 participants (four men and one woman), ranging from 38 to 56
years of age, having between 3 to 18 years of surgical experience and having
performed between zero and 80 da Vinci surgical procedures in the last two
years. All participants had previously undergone standard da Vinci Si and Single-
Site training. All participants had some experience with laparoscopic single
site surgery. All 5 participants were able to complete both separate suturing
and a leak free closure of the enterotomy using the dVSS system in the allotted
time. Conversely, only 3/5 (60%) surgeon was able to complete the task in
the allotted time using laparoscopic single site instruments. Furthermore the
leak rate was high in this group: 90% (9 out of 10). All participant expressed
difficulty or fatigue while performing the laparoscopic task.
Conclusions: The study has demonstrated significantly improved suturing
capability using the da Vinci Single-Site Instruments and Accessories (dVSS)
system compared to laparoscopic single site suturing. Although the number of
participants was low, it appears that the learning curve of robotic single-site
suturing is fast; all participants were able to complete the suturing tasks for their
first trial. The dVSS system has the potential to expand single site surgery to
complex procedures currently not performed with single site technique because
of the difficulty with suturing. Further comparative studies should be performed
with dVSS after it becomes commercially available.
www.mirasurgery.org
P047: COMPARISON OF PERIOPERATIVE OUTCOMES BETWEEN
HAND-ASSISTED LAPAROSCOPIC WHIPPLE’S OPERATION AND
ROBOT-ASSISTED LAPAROSCOPIC WHIPPLE’S OPERATION Eric
C.H. Lai, MBChB MRCSEd FRACS, Chung Ngai Tang, MBBS FRCS, George
P.C. Yang, MBBS MRCSEd FRACS, Oliver C.Y. Chan, MBChB MRCSEd
FRCS, Michael K.W. Li, MBBS FRCS Department of Surgery, Pamela Youde
Nethersole Eastern Hospital, Chai Wan, Hong Kong SAR, China
Introduction: To compare the short term outcome between hand-assisted
laparoscopic Whipple’s operation and robot-assisted laparoscopic Whipple’s
operation.
Methods & Procedures: A non-randomized comparative study was conducted on
18 consecutive patients, who underwent hand-assisted laparoscopic Whipple’s
operation (n=10) and robot-assisted laparoscopic Whipple’s operation (n=8)
between August 2008 and December 2010
Results: Operation for malignant pathology was 90% and 75% for hand-assisted
laparoscopic group and robot-assisted laparoscopic group, respectively. Two
patients in hand-assisted laparoscopic group needed open conversion. There
was no significant difference in mean operating time (315.4 vs. 550.8 minutes),
median blood loss (200 vs. 175 ml), pancreatic fistula rate (30 vs. 37.5%),
bleeding complication rate (30 vs. 0%) and procedure related mortality rate (0
vs. 0%). There was a significant shorter mean hospital stay (33.6 vs. 11.1 days)
in robot-assisted laparoscopic group. There was no significant difference in R0
surgical margin rate (100% vs. 83.3%) for patients with malignant disease.
Conclusion: Robot-assisted laparoscopic approach was feasible, and safe. Robot-
assisted approach also has the advantage of lower complication rate and shorter
hospital stay than hand-assisted laparoscopic approach.
P048: REVISION OF NISSEN FUNDOPLICATION TO ROUX-EN-Y
GASTRIC BYPASS WITH THE ROBOTIC SYSTEM DA VINCI. HC Pappis,
MD PhD FACS, N Pararas, MD PhD, D Kotsakou, MD ’Hygeia’ Hospital,
Athens, Greece
Introduction: We present a case of a morbidly obese patient with BMI 42, who
had previously undergone laparoscopic Nissen fundoplication, successfully
treated by robotic assisted revision to Roux-Y-gastric bypass. We discuss our
initial experience.
Methods & Procedures: The 60-years-old female patient presented to us one year
ago with morbid obesity, hypertension, lower limbs edemas, arthritis and
recurrent gastroesophageal reflux. She had undergone laparoscopic Nissen
fundoplication 10 years previously, with a BMI 32 at that time. Important
steps of the procedure included lysis of all adhesions between the liver and
the stomach, dissection and freeing of the wrap from the crura and the
esophagus, repair of the wide hiatus and complete unfolding of the stomach.
Following that, we created a small gastric pouch and proceeded with the
gastrojejunal linear side-to-side anastomosis and the completion of the
procedure. Operative time was 4 hours and 14 min and postoperative course
was uneventful. The patient was discharged on day 5. At one year follow up
the excess weight loss is 77% with complete recession of co-morbidities and
good general condition.
Conclusions: The conversion of a Nissen fundoplication to RYGB is always
a challenge to the surgeon. This difficult procedure is facilitated with the
Da Vinci Robotic System, which allows better visualization and improved
manipulation in a confined space like the gastroesophageal junction of an
obese patient. From this initial experience, we believe that the robotic system
will improve outcomes and lower postoperative complications in such redo
operations.
P049: ROBOTIC VERSUS LAPAROSCOPIC ROUX-EN-Y GASTRIC
BYPASS: META-ANALYSIS Sheraz R Markar, MRCSEng MAcantab, Alan P
Karthikesalingam, MRCSEng MACantab, Sri Thurumathy, MBBS, James
Kinross, MRCSEng PhD, Paul Ziprin, FRCS PhD Academic Surgical Unit, St
Mary’s Hospital, Imperial College, UK
Introduction: Laparoscopic Roux-en-Y Gastric Bypass (LRYGB) is a well-
practiced surgical treatment option for morbid obesity. However several
limitations such as non-articulating rigid instruments, poor ergonomics and
two-dimensional visualization are attributable to this technique. Robotic
surgery provides increased dexterity, improved ergonomics and a true three-
dimensional and magnified view of abdominal anatomy. However, there is a
47
Poster Abstracts
paucity of comparative evidence to highlight the clinical advantages of robotics
in Roux-en-Y gastric bypass. The aim of this study was to provide pooled
analysis of individually small trials comparing robotic RYGB (RRYGB) with
standard laparoscopic RYGB (LRYGB).
Methods: A systematic literature search of Medline, Embase and Cochrane
Library databases was performed. The search terms “Roux-en-Y”, “Gastric
Bypass”, “Obesity”, “Robotic Surgery” and MeSH headings “Gastric
Bypass”(MeSH), “Laparoscopy”(MeSH), “Obesity”(MeSH), and “Surgery,
Computer-Assisted”(MeSH) were used. The electronic search was
supplemented by a hand-search of abstracts from the European Association for
Endoscopic Surgery, the Clinical Robotic Surgery Association, the Minimally
Invasive Robotic Association, the Surgical Research Society, the Society of
Academic and Research Surgery, the Society of American Gastrointestinal
and Endoscopic Surgeons and the Association of Surgeons of Great Britain
and Ireland. Reference lists of all relevant studies and the Current Controlled
Trials Register were reviewed. Selection criteria comprised randomised
controlled trials or comparative studies comparing robotic and laparoscopic
Roux-en-Y gastric bypass in adults. Primary outcome measures were the
incidence of anastomotic leak and anastomotic stricture. Secondary outcome
measures were post-operative complications, operative time and length
of hospital stay. The weighted mean difference (WMD) was calculated for
continuous variables and pooled odds ratios (POR) for discrete variables using
random-effects models. Heterogeneity was assessed by Cochran’s Q statistic
and the Egger test was used to detect bias.
Results: The literature search retrieved 7 publications for inclusion in this
analysis. In total there were 1686 patients included in the analysis; 1093 LRYGB
and 593 RRYGB. Primary outcome analysis revealed no difference between
the groups in the incidence of anastomotic leak (POR=0.49; 95% C.I.=0.17
to 1.38; P=0.18). However there was a significantly reduced incidence of
anastomotic stricture in the robotic group (POR=0.43; 95% C.I=0.19 to 0.98;
P=0.04). Secondary outcome analysis revealed no significant difference between
the groups in the incidence of postoperative complications (POR=0.79; 95%
C.I.=0.50 to 1.26; P=0.32), operative time (WMD=6.37; 95% C.I.=-4.30 to
17.04; P=0.24) and length of hospital stay (WMD=0.18; 95% C.I.=-0.52 to
0.87; P=0.62).
Conclusion: This pooled analysis of comparative studies demonstrated similar
outcomes for robotic and laparoscopic Roux-en-Y gastric bypass. However,
the incidence of anastomotic stricture was reduced with RRYGB compared to
LRYGB over a minimum follow-up period of 6 months, thus demonstrating
the potential benefit of RRYGB. A possible reason for this reduced stricture
rate associated with robotic gastric bypass could be the technical benefits of
improved 3-dimensional visualization and better ergonomics allowing for more
accurate tissue apposition during anastomosis. This pooled analysis serves
as evidence of the benefit of robotics in Roux-en-Y gastric bypass, however
further randomized controlled trials on this topic will help to elucidate further
differences in clinical outcome.
P050: ROBOT-ASSISTED CHOLECYSTECTOMY AS A BRIDGE TO
ADVANCED ROBOTIC PROCEDURES HC Pappis, MD PhD FACS, N
Pararas, MD PhD, D Kotsakou ’Hygeia’ Hospital, Athens, Greece
Introduction: The value of robotics in general surgery may be for advanced
minimally invasive procedures. The learning curve of these procedures is
quite long, and there are very few opportunities to get familiar with the
robotic system. As a result, most surgeons currently develop robotic skills in
practicing with simple routine operations, such as cholecystectomy. Our goal is
to determine whether robotic cholecystectomy is a safe and effective bridge to
advanced robotics in general surgery.
Methods & Procedures: Before performing advanced robotic procedures, 2 surgeons
had completed the Intuitive Surgical da Vinci training course and agreed to
work together on all procedures. We report on 25 consecutive cases of robot
assisted colecystectomies, including scheduled operations and emergency acute
cholecystitis ones. The console surgeon and the trained assisting surgeon where
always the same.
Results: We studied the cases controlling the time to docking, the operative
time, the possible complications due to the new technique and the efficacy of the
surgeon performing the procedures at the end of the series.
48
Conclusion: Robotic cholecystectomy seams to be the only available training
procedure, that will make the surgeon and the whole team feel comfortable
with the robotic system, allowing lowering of all operating times, minimizing
accidental moves that may cause complications, understanding of the port
positioning that is relatively different than standard laparoscopy and establishing
good communication between the console surgeon and the rest of the team.
Formal fellowship training opportunities for robotic general surgery have to be
established, so as to facilitate the application of robotics directly to advanced
cases, where the advantages of the system are obvious.
P051: DYSFUNCTION OF THE DA VINCI SURGICAL SYSTEM DURING
260 VARIOUS ROBOTIC PROCEDURES. Francois Pugin, MD, Bucher Pascal,
MD, Buchs Nicolas, MD, Hagen Monika, MD, Morel Philippe, MD University
Hospitals Geneva, Switerland
Introduction: The Da Vinci Surgical system is a complex robotic device that offers
stereoscopic vision and 7 degree of freedom instruments for minimally invasive
surgery. Study aim is to evaluate system malfunctions during surgery.
Methods: From January 2006 and December 2010, a total of 260 robotic
surgeries were performed in the division of visceral surgery in our institution.
We analyze retrospectively a prospective database. Dysfunctions were classified
in two groups: robot and instrument malfunctions. Robot failures were
then divided in console, arms, optic and system malfunctions. Instruments
malfunctions were subclassified according to the type of the instruments.
Conversion to open and/or laparoscopy were evaluated.
Results: A total of 11 failures from 260 procedures were noted (4.2%).
There were 3 instrument failures and 8 robot dysfunctions. All instrument
dysfunctions concerned the ultrasonic coagulation device and were solved
during the operation by instrument replacement. The robot malfunction was
related to the arms in 4 cases, due to inadequate position of the adapter between
the arm and the instruments. Repositioning the adapter solved the dysfunction
in all cases. There were 2 minor console dysfunction related the audio control.
No system error was reported. One of the two optic malfunctions led to a
laparoscopic conversion (0.4%), due to light source failure.
Conclusion: The rate of malfunction during robotic visceral surgery is low
and can be solved peroperatively in many cases allowing to the surgery to be
completed safely. Critical failure is very uncommon but can lead to conversion
to either laparoscopy or open surgery.
P052: ROBOTIC-ASSISTED LAPAROSCOPIC TREATMENT OF LIVER
CYSTS Daniel Langer, Miroslav Ryska, Jiri Pudil, Eva Laszikova Surgery
Department, 2nd Faculty of Medicine, Charles University and Central Military
Hospital Prague, Czech Republic
Objective: Hepatic cysts do not fall into common disease group in the middle
Europe. There are non-parasitic cystical lesions in nearly all of the cases. Only
minor part of patients with cystical liver masses suffer from clinical disorders
and vindicate surgery treatment. The authors intention is a short-period results
presentation of robot-assisted liver cyst surgery.
Method: Group retrospective evaluation of 12 patients, who underwent
minimally invasive operative treatment for symptomatic hepatic cyst disease in
our surgery department.
Results: Group of our patient was composed of 9 women (75 %) and 3 man (25
%), average aged 60 years, in range of 40 to 72 years. All operative procedures
were finished in laparoscopic way. Operation duration time averaged 125
minutes. There were only symptomatic cyst masses in our group, localized in
the right hepatic lobe in one half of cases. Cholecystectomy was accomplished
in three patients simultaneously. We have recorded 1 early complication.
Blood losses were negligible with no need of any blood transfusion product
substitution. We revealed just 3 recurrences after operation of our patients. The
average follow-up time was 38 months.
Conclusion: Our laparoscopic liver cyst (polycystosis excepted) surgery experience
supports and advocates laparoscopic treatment to be useful modality with minimal
morbidity and mortality in concordance with literature conclusions. Da Vinci
robotic system has notably assisted in less accessible hepatic segments. Presented
results of our group are comparable with other published conclusions. We rate our
results as temporary considering short term trial.
6 TH ANNUAL MIRA CONGRESS May 11-13, 2011
 P053: TRANSVAGINAL NATURAL ORIFICE TRANSLUMINAL
ENDOSCOPIC SURGERY (NOTES)- AN OVERVIEW Christina Delimpalta,
Archontis Zampogiannis National and Capodistrean University of Athens
Medical School and 1st Surgical Clinic, Laikon Hospital, Athens, Greece
Introduction: Natural orifice transluminal endoscopic surgery (NOTES) represents
the future in minimally invasive surgery. With laparoscopy proving hugely
effective in management of many surgical conditions with better patient outcomes,
the prospective of scarless, painless operations with minimal complications is
alluring to patients and surgeons alike. So far NOTES procedures have been
performed mostly in animal models. Clinical cases are few. Transvaginal NOTES
seems to currently be the most widely used, and this paper reviews published
literature on transvaginal NOTES procedures in humans.
Methods & Procedures: Review of published literature.
Results: NOTES is a technique allowing endoscopes to enter the abdominal
cavity through the viscera. Transgastric, transrectal and transurethral
approaches have been used, but the transvaginal route remains most promising.
It has been used safely by gynecologists for awhile and has none of the inherent
problems of transgastric approach such as danger of fistulization, peritonitis
or gastrostomy leakage. Advantages include minimal or no scarring, less
post-operative pain, better patient mobilization, low risk of herniation or
dermal wound complications and less adhesion formation. It is safe for obese
patients and those with abdominal wall malformations. Hybrid NOTES is the
combination of transvaginal and laparoscopic techniques, while Totally NOTES
is performed without abdominal wall penetration. The most widely performed
operation is NOTES cholecystectomy, mainly because it is the most feasible
operation in which rigid laparoscopic tools can be used. Most surgeons place
an umbilical trocar to create the pneumoperitoneum and facilitate gallbladder
mobilization, while removing the organ through the colpotomy. Totally
NOTES cholecystectomy has been reported using two endoscopes via vaginal
incision. However, most surgeons advocate use of hybrid NOTES to ensure
operation safety until appropriate tools are manufactured, especially in abdomes
with adhesions from previous operations. Other operations performed using
NOTES include appendectomy and peritoneal tumor staging, while hybrid and
totally NOTES nephrectomies have also been reported. Transperitoneal and
retroperitoneal adrenalectomies and pancreatectomies have been performed in
pigs and, if safely applied to humans, will minimize the need for dissection or
retraction of the surrounding organs and allow direct access with less systemic
risk. NOTES’ most important disadvantage is the lack of appropriate tools.
Flexible endoscopes are not easily used in the peritoneal cavity and use of
laparoscopic tools leads to instrument collision and inadequate exposure and
tissue handling. Development of Magnetic Anchoring and Guidance System
(MAGS) with instruments deployed intra-abdominally and maneuvered
by external magnet promise to provide solutions. Although relatively safe,
transvaginal NOTES still caries risk of bowel perforation, herniation,
postoperative infection, visceral lesions and adhesions. With no long-term
follow-up dyspareunia, infertility, and spread of pre-existing endometriosis
represent potential complications and many surgeons advocate NOTES use only
in women who desire no further pregnancies. Other reported complications
include vulvar laceration, Douglas pouch abscess and subhepatic collection.
Conclusions: NOTES is emerging as a breakthrough evolution in surgery. Its
theoretical advantages are many, but so are the difficulties to be overcome. It is
accompanied by its own, method-specific set of problems that must be addressed
and resolved before it gains widespread approval.
P054: NOVEL SLIP AND TACTILE SENSOR SYSTEM ON A MIOGRIPPER
Luis Gerardo Sanchez Stone, MSc, Abel Ronquillo, MSc UPAEP, ERGOSOLAR,
LAAR L. G. Sánchez
Novel myoelectric hand prosthesis design with MEMS slip sensors.
Abstract— The hand design is based in a three-digit clip that allows to perform
flexion and extension movements manipulated by myoelectric signals coming
from the muscle: radial extensor and radial flexor. Pronation and supination
movements of the wrist are manipulated manually by a circular adapter that
performs the interconnection between the hand and the socket to give it a fixed
alignment.
With respect to the electrodes that transmit the myolelectric signals, those were
inserted in the patient socket to avoid problems finding the exact location of the
signal transmitter muscle. Through an special software, it is possible to find the
www.mirasurgery.org
best electrodes position for every patient, train the patient, and design a simple
adaptable personalized socket which will properly fit every patient and the
electrodes will be automatically in contact with the optimum transmitter points
above the skin.
Electronic circuits contain components that enable suitable bioelectric signal
acquisition and an ideal stage filters to reduce environmental and biological
noise. The signal amplified and filtered, manipulates in the power amplifier
stage, the motor through an “H” bridge to achieve the movement of the clamp.
The clip has been equipped with surface pressure sensory in order to feedback to
the system so as to achieve better control and manipulation of objects. A novel
PVDF MEMS slip sensor is designed and presented.
This work presents the complete development of a myoelectric prosthesis,
showing progress in the functional integration of these technologies, achieving a
high quality system technology and a relatively lower cost.
It is remarkable for the development of this design, that it is possible to
achieve better sensitivity results than the commercially available sensors
(20-30 pC/N), since the shapes of the pyramids provide theoretical better
mechanical performance when measuring the shear forces. Since the material
PVDF is a material available in the actual market and with a low cost ratio, the
implementation of this sensor will help to provide high technology to any social-
economic status.
The signal obtained from the slip sensor could be then used to automatically
control de oppression of the gripper with the object being handled.
With this smart automatic slip control system, it is then possible to reduce de
training timing for a new user of a prosthetic hand.
Since we have an array of sensors, with a special pyramid shape, the sensitivity
could then overcome the problems of this kind of sensors commonly used.
The tests show sensitivity improvement, as well as integration of the sensor to
the electronics of the system, the autonomous of the movements and finally the
field tests.
In the field of BioMEMS there are several opportunities in the biomedical field,
such as adapt this kind of sensors for sensible quirurgical robots. Whit the
biomaterials used in this sensor, this kind of systems can be successfully applied
in the medical field.
P055: IN SILICO EXPERIMENTAL MODEL OF AN ASSEMBLING
RECONFIGURABLE MODULAR MICRO-ROBOT FOR NOTES SURGERY
Apollon Zygomalas, MD MSc, Konstantinos Giokas, MSc, Dimitrios Koutsouris,
Prof University of Patras, School of medicine, Postgraduate Course in Medical
Informatics
Introduction Natural orifice transluminal endoscopic surgery (NOTES) is
currently the most interesting achievement of surgery. Micro-robots can be used
in NOTES in order to approach intra-abdominal organs. The objective of our
study is to develop and simulate in silico an assembling reconfigurable modular
micro-robot which could be used in NOTES surgery.
Methods & Procedures: A professional robot simulation application (Webots
PRO 6.0) has been used for the development, programming and simulation of
the micro-robotic system. Simple design with basic 3D objects and motion-
mechanical characteristics have been used. Physics algorithms and motion
properties have been evaluated.
Results: Our experimental micro-robot consists of small subunits that can be
swallowed or enter throughout the natural human orifices into the abdominal
cavity of the patient. The subunits are been assembled in order to build a
reconfigurable modular micro-robot. Three kinds of subunits have been
developed; an endoscopic subunit, a surgical instrument unit and a body unit.
Two types of robots can be assembled depending on the kind of the frontal
subunit (endoscopic robot, surgical instrument robot). A modular remote
controlling system has be used in order to control the robot which operates in
the abdominal cavity. Using this controlling system approach the position of
each subunit of the modular micro-robot is always visibly known. The controller
helps the surgeon to try different formations for his robot without changing
the formation of the micro-robot itself. Although the formation of the modular
micro-robot is always known, its intrabdominal position and orientation is not
always predictable. In order to achieve satisfactory motion and operational
abilities more than 3 body subunits should be used.
49
Poster Abstracts
Conclusions: Our experimental modular micro-robot model can serve as the basis
for the development of a more complex micro-robotic system which can be used
in NOTES surgery. The novel approach of modular remote controlling system
can facilitate the improvement of controlling systems for complex robots and the
development of sophisticated remote modular micro-robot controllers. Since the
live human organism cannot be easily simulated there is the need of an in vivo study.
P056: SOFIE, A ROBOTIC SYSTEM FOR MINIMALLY INVASIVE SURGERY
Linda Van den Bedem, dr ir, Ron Hendrix, ir, Gerrit Naus, dr ir, Ruud Van der
Aalst, ir, Nick Rosielle, dr ir, Henk Nijmeijer, prof dr, Jos Maessen, prof dr,
Ivo Broeders, prof dr, Maarten Steinbuch, prof dr ir Eindhoven University of
Technology, the Netherlands, Academic Hospital Maastricht, the Netherlands,
Meander Medical Center Amersfoort, the Netherlands
Developments in surgery are aimed at increasing patient value by improving
the efficacy of procedures and decreasing patient trauma. In line with these
developments, surgeons nowadays employ robotic systems for minimally invasive
surgery (MIS). At the Eindhoven University of Technology, the Netherlands,
Sofie is developed, a new robotic system for minimally invasive surgery. The
system provides haptic feedback, precision, a compact design and high dexterity,
enabling a further increase in patient value.
Sofie is a so-called robotic master-slave system, shown in the figure. The master
is operated by the surgeon, thus controlling the slave robot, which in turn
manipulates the instruments. Two pen-shaped handles form the interface to the
surgeon. In combination with visual feedback, the interface creates an intuitive
working environment by virtually placing the hands of the surgeon on the
instrument part inside the patient. The surgeon’s hand movements are measured
using high-resolution encoders, enabling accurate control of the slave robot
movements. A motor for each degree of freedom in a handle of the interface
provides haptic feedback of the instrument force to the surgeon. Where possible,
a direct drive minimizes friction [1,2].
Developments in robotic MIS often focus on compliant mechanisms for the
slave robot, complicating dynamic force measurements required for haptic
feedback. In contrast, the basis of the Sofie slave consists of a pre-surgical setup
that is rigidly connected to the operating table. A platform is positioned above
the patient. From the platform, the robotic arms manipulate the individual
endoscopic instruments with respect to the patient. This layout leads to a short
and stiff force-path between the instruments, as well as between the instruments
and the operating table. The short and stiff force-path is advantageous for
the dynamic system behavior. Accurate force measurements used for haptic
feedback, facilitate high accuracy handling up to 10 Hz.
Furthermore, the layout results in a compact, lightweight and robust design.
The compactness of the design improves access to the patient during surgery and
reduces the system mass considerably. Moreover, the system is easy to handle
and pre-surgery setup of the system can be done quickly. Finally, an ’elbow-
wrist’ configuration at the tip of an instrument provides high dexterity in the
surgical area, reducing deflection of the external manipulating arm [3].
To date, a proof-of-concept of the slave and a preliminary master are available.
Furthermore, a hardware cabinet with software is available, enabling control
of the slave robot using the master. Haptic feedback to the surgeon is developed
further after successful preliminary tests with the team surgeons. Completion of
the proof-of-concept is scheduled for mid-2011.
[1] R. Hendrix, P.C.J.N. Rosielle and H. Nijmeijer (2009), Design of a haptic
master interface for robotically assisted vitreo-retinal eye surgery, Int. Conf.
Adv. Robot., pg. 1-6.
[2] J.H. Grasman (2008), Mechanical design and construction of a 5 DOF haptic
master device for an eye-surgery robot, Technical report, DCT 2008.111,
Eindhoven University of Technology.
[3] L.J.M. van den Bedem (2010), Realization of a demonstrator slave for robotic
minimally invasive surgery, Ph.D. thesis, Eindhoven University of Technology.
P057: ROBOTICALLY ASSISTED UKA IS MORE ACCURATE THAN
MANUALLY INSTRUMENTED UKA Thomas M Coon, MD, Matthew
D Driscoll, MD, Sharon Horowitz, BS, Michael A Conditt, PhD St Helena’s
Hospital, Scott and White Memorial Hospital, MAKO Surgical Corp
Introduction: Successful clinical outcomes following unicompartmental knee
arthroplasty (UKA) depend on accurate component alignment, which can be
50
difficult to achieve using manual instrumentation. A new technology has been
developed using haptic robotics that replaces traditional UKA instrumentation.
This study compares the accuracy of UKA component placement with
traditional jig-based instrumentation versus robotic guidance.
Methods: 85 UKAs performed using standard manual instrumentation were
compared to 67 performed with a robotically guided implantation system
without instrumentation. Each was performed using a minimally invasive
surgical approach. The two groups were identical in terms of age, gender
and BMI. The coronal and sagittal alignment of the tibial components were
measured on pre- and post-operative AP and lateral radiographs. Postoperative
tibial component alignment was compared to the pre-operative plan.
Results: The RMS error of the tibial slope was 3.7° manually compared to 1.2°
robotically. In addition, the variance using manual instruments was 9.8 times
greater than the robotically guided implantations (p<0.0001). In the coronal
plane, the average error was 3.0 ± 2.2° more varus using manual instruments
compared to 0.3 ± 1.9° when implanted robotically (p<0.0001), while the
varus/valgus RMS error was 3.7° manually compared to 1.8° robotically. The
average depth of medial tibial plateau resection was significantly less with inlay
tibial components (3.9 ± 0.9mm) relative to onlay tibial components (6.8 ±
0.9mm, p<0.0001). In addition, a significantly higher percentage of robotic
inlay patients went home the day of surgery (12% vs. 1%, p<0.0001).
Conclusion: Tibial component alignment in UKA is significantly more accurate
and less variable using robotic guidance compared to manual, jig-based
instrumentation. By enhancing component alignment, this novel technique
provides a potential method for improving outcomes in UKA patients.
P058: SLEEVE GASTRECTOMY FOR MORBID OBESITY WITH THE
USE OF THE DA VINCI SURGICAL SYSTEM. A. Alexandrou, Ioannis
Papanikolaou, D. Diamantis, N. Dimitriou, N. Mpasios, J. Griniatsos, A.
Giannopoulos, Theodoros Diamantis 1st Department of Surgery of the
University of Athens, Laiko Athens General Hospital, 17 Agiou Thoma St,
11527, Athens, Greece.
Background: Laparoscopic sleeve gastrectomy (LSG) is used with increasing
frequency for the treatment of morbid obesity. Robotic techniques have been
mainly used for the performance of Roux-en-Y gastric bypass. We report herein
our experience with LSG performed with the use of the Da Vinci surgical system.
Methods: Twenty-three consecutive patients underwent LSG with the use of the
Da Vinci surgical system. Surgical techniques followed the principles of standard
LSG. Preparation of the stomach was performed by the console-surgeon and its
division with the staplers by the patient-side surgeon.
Results: Nineteen women and four men with a mean body mass index (BMI)
of 48.3 kg/m2 were operated. Mean operative time was 95.8 +/- 11.2 min.
Docking time was 16 +/- 4.1 min. There were no conversions. Peri-operative
morbidity and mortality was zero. Time to BMI ratio for robotic LSG was 2 +/-
0.4 min/kg/m2 and it was equal to the respective of our standard LSGs. When
the docking time was excluded, the same ratio was 1.6 +/- 0.1, significantly
shorter than the respective 2.1 +/- 0.5 of our conventional LSGs (p = 0.016).
Mean excess body weight loss 1 year post-operatively was 66.4 +/- 25.2%.
Conclusions: Robotic laparoscopic sleeve gastrectomy is a feasible, safe, and
efficient surgical technique for the treatment of morbid obesity. The use of the
Da Vinci increases the self-confidence of the surgeon thus reduces the pure
operative time of the procedure.
P059: CAN TOTALLY ROBOTIC LAPAROSCOPIC GASTRIC BYPASS
FOR MORBID OBESITY PRECISELY DUPLICATE ANY TRADITIONAL
LAPAROSCOPIC TECHNIQUE? A. Alexandrou, Ioannis Papanikolaou,
D. Diamantis, N. Dimitriou, N. Mpasios, J. Griniatsos, A. Giannopoulos,
Theodoros Diamantis From the 1st Department of Surgery of the University
of Athens, Laiko Athens General Hospital, 17 Agiou Thoma St, 11527, Athens,
Greece
Background: Laparoscopic RYGBP for morbid obesity is a demandino operation.
Robotic techniques have been shown to ameliorate the technical difficulties
thus causing a reduction of the peri-operative morbidity, mainly by simplifying
the construction of the gastrojejunal anastomosis (GJ). Robotic LRYGB has
been reported either as totally robotic with manual suturing of the GJ or as
robotically assisted with the use of the robot only for the GJ. We report a series
of totally gastric bypass patients with semi-manual GJ.
6 TH ANNUAL MIRA CONGRESS May 11-13, 2011
 Patients & Methods: Nine consecutive paients underwent totally robotic LRYGBP.
The GJ was fashioned with a combination of use of the linear stapler and manual
suturing.
Results: Mean preoperative BMI was 45.3 +/- 4.7 Kg/m(2). In one case we had to
undock the Da Vinci Surgical System at the time of the jejunojejunostomy due to
unfavourable ergonomic. Mean time to dock the robot was 16.3 +/- 3.5 minutes
while mean total operative time was 197.2 +/- 12.3 minutes. Immediate
postoperative morbidity and mortality equalled zero. The mean EWL rate one-
year post-op was 79 +/- 15%.
Conclusion: Totally robotic LRYGBP can duplicate precisely any conventional
technique without any compromise in operative time, short- or long- term results.
P060: REMOTE TELE SURGERY : HELP OF LOSSY VIDEO
COMPRESSION FOR THE FUTUR Manuela Perez, MD, Nedia Nouri, Jean-
Marie Moureaux, Denis Abraham, Michel Dufaut, Jaques Hubert, PhD Centre
de Recherche en Automatique de Nancy, Nancy-Université, CNRS 2, avenue de
la forêt de Haye, 54516 Vandœuvre-lès-Nancy, France 2 Centre de Recherche
en Automatique de Nancy, Nancy-Université, CNRS Faculté des Sciences, BP
70239, 54506 Vandœuvre-lè
Introduction: Progress of robotic-assisted surgical techniques allows today
mini-invasive surgery to be more accurate, providing benefits to patients
and surgeons for complex surgical procedures. Remotes telesurgery are
sporadically described since 2001 with the "Operation Lindbergh". The
medical video from the da Vinci? represent a high requires significant
bandwidth. An appropriate solution to reduce the amount of data could be
found among the various existing lossy compression schemes. The aim of this
study is to determine the compression threshold tolerated by surgeon in an
application of telesurgery through a subjective assessment of the quality of
video encoded using the MPEG2 algorithm.
Methods & Procedures: We design a study based on surgeons’ evaluation of
compressed surgical video from the da Vinci using the Double-Stimuli
Continuous Quality Scale (DSCQS) from the International Telecommunication
Union (ITU-R BT-500-11 recommendations) that give the general test viewing
conditions for subjective assessment of the quality of television pictures. The
DSCQS is base on the comparison between a native video reference A and the
same video compressed B. This video sequences A and B are presented to the
surgeon. For each pair he give a’quality score’ by marking on a continuous line.
The line is divided into five equal lengths ranging from Excellent’ to ’Bad’.
The scores obtained by each sequence were processed as the difference in
judgment between reference and impaired sequences. Seven robotic surgeons
were involved in the sudy. Four sequences were selected from several typical
surgical operation cases submitted at many sequences Bit-rates from 1,02 to
8,04 Mbits/s. Sequence 1 represents a surgical laparoscopic instrument motion;
Sequence 2 a blood clotting with a bipolar forceps; Sequence 3 a fat area and
Sequence 4 a compress application. The video sequences were displayed to
observers thanks to the viewing facilities of the robotic-assisted console in the
operating theatre typical conditions.
Results: Sequences 2 and 3 appeared to be non critical. Hopefully, sequences 1
and 4 allow us to determine regression curve, with coefficient of determination
corresponding to the dispersion of points compared to the curve provides at
R²=0.6245 (sequence 1) and R²=0.9117 (sequence 4). These values show a good
homogeneity between assessors. This regression curve allow us to identify, with
a good precision, the threshold, above which no loss of quality is perceived and
below it only a poor quality can be expected. This threshold is 3.2 Mbits/s,
above, no surgeon perceived any loss of quality due to bit-rate reduction. The
initial video requested initially 270 Mbits/s to be transmitted and it represent a
compression ratio of around 90:1.
Conclusion: One of the main results of this study is that, not only using lossy
compression for medical video transmission seems possible, but also one can
determine a threshold above which no surgeon perceives any loss of quality
with a compression ratio around 90:1. This very promising conclusion is high of
importance, unlocks one of the technical locks to transmission of medical video
and opens doors to distant-teaching, distant-mentoring and soon distant-surgery
using network transmission.
www.mirasurgery.org
P061: RESULTS OF A PROFICIENCY-BASED CURRICULUM WITH THE
VIRTUAL REALITY ROBOTIC SURGERY SIMULATOR: DV-TRAINER.
Perrenot Cyril, Perez Manuela, MD, Tran Nguyen, MD, Hubert Jacques, MD
CHU de Nancy
Objective of the Study: Development of robotic surgery involves training and
assessment of specific skills. Training on animal model or in operating room is
expensive and expose to medico-legal implications of learning curve. Virtual
reality simulators are an interesting alternative, already use in laparoscopy
since many years but still under development for robotic surgery. The aim of
this study is to define the learning curve and time needed for a proficiency-
based curriculum on the dV-Trainer (MIMIC Technologies®), a virtual robotic
surgery simulator.
Methods & Procedure: Prospective study, from December 2010 to Februar 2011,
using three robotic surgery simulators dV-Trainer set up in our school of
surgery. 14 surgeons (all beginners in robotic surgery, less than 5 cases) were
recruited. Twenty-two exercises divided in six levels were included. All subjects
performed the exercises in the same order and were allowed to start next
exercise only when they rise proficiency (defined as 90% of the expert level).
The analysis was based on 3499 scores of the simulator.
Results : All subjects were able to complete the twenty-two exercises of the
training program until proficiency level. They needed between 5 to 12.2 +/- 3.3
hours to finish it. The mean number of attempt for each exercises was 11.4 +/-
3.8 attempts. The mean time for one exercise was 154.2 sec +/- 19.5 sec.
Conclusions: Using a proficiency-based training program for dV-Trainer is highly
feasible and the mean time to rise proficiency is achievable during a residency
training program. The robotic surgery simulator is a valid tool for robotic training.
P062: ACCURACY OF ROBOTICALLY ASSISTED ACETABULAR CUP
IMPLANTATION Douglas E Padgett, MD, Lawrence D Dorr, MD, Miranda
L Jamieson, MS, Michael A Conditt, PhD Hospital for Special Surgery, Good
Samaritan Hospital, MAKO Surgical Corp
Introduction: Recent gains in knowledge reveal that the ideal acetabular cup
position is in a narrower range than previously appreciated and that position
is likely different based on femoral component anteversion. For that reason
more accurate acetabular cup positioning techniques will be important for
contemporary THA. It is well known that malalignment of the acetabular
component in THA may result in dislocation, reduced range of motion or
accelerated wear. Up to 8% of THA patients have cups malaligned in version by
more than ±10º outside of the Lewinnek safe zone. This type of malalignment
may result in dislocation of the femoral head and instability of the joint within
the first year, requiring reoperation. Reported incidences of reoperation are
1-9% depending on surgical skills and technique. In addition, cup malalignment
is becoming increasingly important as adoption of hard on hard bearings
increases as the success of large head hard on hard bearings seems to be more
sensitive to cup positioning. This study reports the accuracy of a haptic robotic
system to ream the acetabulum and impact an acetabular cup compared to
manual instrumentation.
Methods: Six fresh frozen cadaveric acetabula were CT scanned and three-
dimensional templating of the center of rotation, anteversion and inclination of
the cup was determined pre-operatively. Half of the specimens were prepared
with manual instrumentation while half were prepared with robotic guidance.
Haptic and visual feedback were provided through robotics and an associated
navigation system to guide reaming and impaction of the cup. The robot
constrained the orientation and position of the instruments thus constraining
the inclination, anteversion and center of rotation of the reamer, trial and
the final cup. Post-operative CT’s were used to determine the achieved cup
placement and compared to the pre-operative plans.
Results: In all cases, robotic guidance resulted in placement of the acetabular
cup within ±3° of anteversion, ±3° of relative to the pre-op plan. The average
absolute inclination error was 1.5±1.2° and the average absolute anteversion
error 1.3±1.4°. Cup placement with robotic assistance was significantly
more accurate and precise than with manual instrumentation. With manual
instrumentation the errors were, on average, 4.2 times higher in inclination and
4.8 times higher in anteversion compared to robotic instrumentation.
Conclusion: This haptic robotic system substantially improved the accuracy of
acetabular reaming and placement of the final cup compared to traditional
manual techniques. With greater knowledge of ideal acetabular cup position,
51
Poster Abstracts
highly accurate techniques may allow surgeons to decrease the risk of
dislocation, promote durability and improve the ability to restore appropriate
leg length and offset. Haptic robotics has proven to be safe and effective in both
knee and hip surgery and provides the potential to redefine the “instrument set”
used for orthopedic procedures.
P063: ACCURACY OF UKA COMPONENT PLACEMENT WITH
DYNAMICALLY REFERENCED TACTILE ROBOTICS Nicholas D Dunbar,
MS, Martin W Roche, MD, Brian H Park, BS, Sharon Horowitz, BS, Michael A
Conditt, PhD, Scott A Banks, PhD Holy Cross Hospital, University of Florida,
MAKO Surgical Corp
Introduction: Unicompartmental knee arthroplasty (UKA) can achieve excellent
clinical and functional results for patients suffering from single-compartment
osteoarthritis. However, UKA is considered to be more technically challenging
to perform, and malalignment of the implant components has been shown
significantly to contribute to UKA failures. It has been shown that surgical
navigation and tactile robotics could be used to provide very accurate
component placement when the bones were rigidly fixed in a stereotactic
frame during preparation. The purpose of this investigation was to determine
the clinically realized accuracy of UKA component placement using surgical
navigation and tactile-robotics when the bones are free to move.
Methods: Complete records, including pre-op CT, post-op CT, and surgical plan
were available for 22 knees out of the first 45 procedures performed using a
new tactile-guided robotic system. Three-dimensional component placement
accuracy was assessed by comparing the pre-operative plan with the post-
operative implant placement (desired versus actual). Errors were assessed as
single axis root-mean-square (RMS) entities.
Results: Femoral component RMS placement errors averaged 1.4 mm/2.6º
along any single axis. Tibial component RMS placement errors averaged 1.18
mm/2.14º along any single axis.
Discussion & Conclusion: Using traditional manual instruments, Cobb et al. found
average RMS errors of 2.20mm/5.48º. Using the robotic approach with bones
fixed, Cobb et al. reported RMS errors of 1.11 mm/2.5º, directly comparable to
our results with bones moving freely during surgery. These results suggest excellent
implant placement accuracy can be achieved using tactile robotics, and suggest
excellent results are achieved in what typically would be considered a learning phase.
P064: HAPTIC ROBOTICS FOR MINIMALLY INVASIVE, MODULAR
KNEE ARTHROPLASTY Scott A Banks, PhD, Rony Abovitz, MS, Arthur
Quaid, PhD, Jason K Otto, PhD, Michael A Conditt, PhD University of Florida,
MAKO Surgical Corp
Total knee arthroplasty (TKA) has evolved over the past 40 years to a point where
it now is a routine treatment with fairly predictable outcomes. However, TKA is an
end-stage treatment which frequently is used when only one or two compartments in
the knee are damaged. Ideally, treatments for earlier stage and isolated disease would
be available to provide the same high level of outcome predictability, but provide
for isolated treatment of the affected compartments, greater levels of postoperative
physical activity and the shorter convalescence demanded by younger, more active,
and often employed patients. One approach to a compartment-by-compartment
treatment regime is the utilization of discrete condylar unicompartmental prostheses
and a patello-femoral prosthesis in any combination. This approach has been
practiced in some European clinics for decades with good reported outcomes.
However, it remains a major surgical challenge to optimally place multiple discrete
arthroplasty components using conventional tools and small incisions. This lecture
will present a detailed overview of a unified approach to minimally invasive, modular
knee arthroplasty using haptic robotic instrumentation (Tactile Guidance System
2.0, MAKO Surgical, top right) and implants designed specifically for robotic
installation in a customized modular treatment regime (MAKO Modular Knee,
MAKO Surgical, bottom right).
Haptic robotics provide a ’virtual cutting guide’ capability permitting precise
sculpturing of bone surfaces using near-zero-visibility minimally invasive
incisions. The use of a single-multifunctional tool eliminates many of the
instrument trays commonly needed for these procedures. The surgeon has
complete control in manipulating the bone cutting tool within the desired bone-
removal area, but the haptic robotics prohibit the cutting tool from removing
bone outside the planned bone removal volume. Precise bone sculpturing has
the potential to minimize bone removal and optimize the alignment and fixation
of the prosthetic components.
52
Haptic robotic cutting tools obviously can be used with off-the-shelf prosthetic
components, but this approach would fail to fully take advantage of the precision
surfaces that can be achieved using robot assisted bone sculpting. Instead, a
purpose built system of modular knee components can be defined that work in
any combination (medial or lateral unicompartmental, bi-unicondylar, medial
or lateral plus patellofemoral, or tricompartmental), require minimum bone
removal, can be placed through very small incisions, give great flexibility to
customize implant placement to fit the patient’s anatomy, and take advantage
of the types of fixation features which easily are created with a robotically
controlled bone cutting device.
The current treatment implementation and implant design will be presented.
Clinical results for unicompartmental procedures and in vitro results for
multiple-compartment procedures will be presented and discussed.
P065: THE LEARNING CURVE OF ROBOTIC-ASSISTED UKA Riyaz
Jinnah, MD, Sharon Horowitz, BS, Tamas Erdos, BS, Michael A Conditt, PhD
Wake Forest University, MAKO Surgical Corp
Introduction: Successful clinical outcomes following unicompartmental knee
arthroplasty (UKA) depend on accurate component alignment, which can be
difficult to achieve using manual instrumentation. A new technology has been
developed using haptic robotics that replaces traditional UKA instrumentation.
Integrating new technology into the operating room can be associated with
a significantly long learning curve, which introduces inefficiency in to the
surgeon’s practice and the hospital’s OR work flow. This study quantifies the
learning curve of a new technology developed to improve the accuracy of UKA.
Materials & Methods: Two hundred forty four patients received a UKA performed
five different surgeons with a robotically guided implantation system employing
a CT based pre-operative plan implemented using a haptic-guided burr for all
bone resection. Each surgeon had performed at least 30 surgeries with the new
technology. As the philosophy of each surgeon differs in terms of tourniquet
use, the time from the insertion of the first bone pin to the acceptance of the
final trial components was measured. This time frame includes attachment of
navigation markers to the femur and the tibia, three-dimensional registration
of actual boney surfaces to the digital reconstructions, and bone resection. The
surgical time of the final 20 surgeries of each surgeon was averaged for a steady
state surgical time. For each surgeon, the number of surgeries required to have 2
consecutive and 3 total surgeries completed within the 95% confidence interval
of the steady state surgical time of that particular surgeon was also noted.
Results: The average surgical time for all surgeries across all surgeons was 59 ±
21min (range: 27min to 165min). This includes both the learning curve cases as
well as the steady state cases. The surgeon with the shortest steady state surgical
time averaged 43 ± 8min, while the surgeon with the longest steady state
surgical time averaged 76 ± 16min. The number of surgeries required to have
2 consecutive surgeries completed within the 95% confidence interval of the
steady state surgical time was 7 (range: 4 to 12). The number required to have
3 surgeries completed within the 95% confidence interval of the steady state
surgical time was 8 (range: 5 to 13).
Conclusions: New technology has been introduced that essentially replaces
traditional manual instrument sets with a passive robotic arm that precisely
executes a pre-operative plan.. The learning curve of this novel surgical technique
is reasonable and is much shorter than has been reported with the introduction
of other orthopedic technologies in the OR. For example, the efficiency learning
curve associated with using surgical navigation for TKA has been reported to be
around 30 cases. New techniques such as hip resurfacing have been associated
with learning curves as high as 70 cases. While the surgeons in this study may
be classified as early technology adaptors and 2 of the 5 surgeons had previous
experience with surgical navigation, an average learning curve of 8 cases is very
promising for the acceptance of this novel robotic-guided surgical technique.
P066: ROBOTIC SLEEVE GASTRECTOMY. AN INTERMEDIATE
APPROACH TO UNDERGO TOTALLY ROBOTIC GASTRIC BY-PASS.
Ramon Vilallonga, PhD, Jose Manuel Fort, PhD, Miriam Zamora, Montserrat
Chinchilla, Nuria Ros, Oscar Gonzalez, PhD, Manel Armengol Carrasco, PhD
Universitary Hospital Vall d’Hebron. Barcelona.
Objective and Study Technique Novel techniques such as laparoscopic sleeve
gastrectomy (LSG) ais now used for the treatment of morbid obesity. In fact, the
only publish article to our knowledge has been inaugust 2010. There is now enough
experience with LSG in our group and we had the possibility to begin robotic sleeve
6 TH ANNUAL MIRA CONGRESS May 11-13, 2011
 gastrectomy. The application of robotic techniques has been reported for bariatric
operations like laparoscopic Roux-en-Y gastric bypass and laparoscopic adjustable
gastric banding, and more recently (august 2010) for LSG. We report herein our
initial experience with LSG performed with the use of the Da Vinci surgical system
as a previous step before Robotic Roux-en-Y gastric bypass.
Description of the Method: Eighteen consecutive patients underwent LSG with
the use of the Da Vinci surgical system by the same surgical team. Surgical
techniques followed the principles of standard LSG. We used three 12 mm
standard trocars and a 8mm DaVinci trocar to perform this novel technique.
The 8-mm metallic robotic ports were inserted through the standard, disposable
12-mm trocars. Preparation of the stomach was performed by the console
surgeon alone and its division with the staplers by the patient-side surgeon. We
completed a sleeve gastrectomy at 2 or 5 cm from the pylorus with a 36F boggie
inside the stomach and performing stappeling through a standard 12 mm trocar.
A complete robotic prolene® suture for reinforcment. Also Seamguald® was
used as reinforcements. A drain is finally placed next to the sleeve.
Prelinimary Results: Twenty patients (2 men and 18 women) with a mean age of
44.4 years (17-63) and a mean body mass index (BMI) of 48.0 kg/m2 were
operated by Robot. Mean total operative time (including docking time) was
104.1±15.3 min. Mean set-up time was 35 minutes and mean docking time
was 6 min. There were no conversions. Complete robotic prolene® suture
for reinforcement was performed in 14 patients. Also Seamguald® was used
as reinforcements in 6 patients. Peri-operative morbidity and mortality was
zero. Mean time for discharge was 4.16 days. We had a patient who required a
conversion to laparoscopic gastric by-pass after one month because of an unusual
complication of curling stomach. Mean BMI at 3 months post-operatively was
35.8± 25.6%. The procedure can be completed with only one assistant and with
four trocars instead of five in LSG.
Conclusions/Expectations: Robotic laparoscopic sleeve gastrectomy is a feasible
and safe approach. In experienced laparoscopic hands it is still an efficient
surgical technique for the treatment of morbid obesity. No added operating
time for the procedure has been reported. The application of robotics to
this type of surgery might have less obvious advantages than with LRYGBP.
However, to our knowledge few groups use the Da Vinci system in the world.
Our Group has considered as a novel and first approach before being involved
in Robotic Gastric Bypass.
P067: DEVELOPMENT OF AN AUTOMATED REAL-TIME MR GUIDED
ROBOTIC SYSTEM FOR HIGH PRECISION DIAGNOSTIC AND
THERAPEUTIC INTERVENTIONS IN BREAST. Mehran Anvari, MB BS PhD
FRCSC FACS, Julian Dobranowski, MD FRCPC, Kevin J Randall, PhD, Peter
Lovrics, MD FRCSC, N Konyer, BSc, T Fielding, MSc, K Morency, MSc Centre
for Surgical Invention and Innovation; MacDonald, Dettwiler and Associates
Contrast Enhanced (CE) Magnetic Resonance (MR) imaging has proven to
be the most sensitive imaging modality in the detection of breast cancer for
lesions occult in conventional X-ray and Ultrasound mammography. Recently,
minimally invasive MR-guided biopsy techniques have been developed
to extract core samples under MR guidance as an out-patient procedure.
However, in current, commercially available, systems the procedure is
performed out of bore and requires the patient to be shuttled in and out of the
magnet several times. Ultimately the procedure is time consuming, accuracy
is compromised, and most importantly, target verification is lost. It has been
reported, for example, that as many as 8% of CE-MR guided biopsies miss
the target lesion. Clearly a more accurate MR guided biopsy procedure is
desirable.
In the current system the procedure will be performed under real time
guidance with the patient remaining in the bore of the MR imager. Given the
limited space, and the high field (magnetic and rf) environment the robotic
system faced significant design and development challenges. The CSii device
is the first compact high precision system with independent linear (x,y,z)
and angular (pitch, yaw) degrees of freedom. The positioning system and
image registration method for the current device are intrinsically superior to
existing out-of-bore systems. With 5 degrees of freedom the physician is able
to select an optimized trajectory to the target lesion. The planned trajectory
is overlaid on the 3D workstation display and, once confirmed, the control
system autonomously guides the device using redundant position sensors to
maintain track by cross checking with MR position data. Real time guidance is
critical for patient safety as well as instant confirmation of targeting accuracy.
www.mirasurgery.org
Initial test results using breast phantoms in a GE 3T MR system are presented
that demonstrate the significant advantages of the present biopsy system. In
addition, it is proposed that the system will be a valuable tool for ablative
therapy using real-time MR thermometry.
P068: 3D VISUALIZATION AND TRAJECTORY PLANNING SYSTEM FOR
REAL TIME INTERVENTION Mehran Anvari, MB BS PhD FRCSC FACS,
Bart Verzijlenberg, MSc, Julian Dobranowski, MD FRCPC, Kevin Randall,
PhD Centre for Surgical Invention and Innovation; MacDonald, Dettwiler and
Associates
There is no doubt that automated robotics will augment diagnostic and
therapeutic interventions. The high precision targeting accuracy achievable by
a robot will enhance the placement accuracy of a diagnostic or therapeutic tool
to the site of a detected lesion to within fractions of a millimeter. However,
although physicians are currently trained to diagnose and perform interventions
based on 2D clinical images, there are limitations in procedures such as core
needle biopsy, since needle trajectory will rarely lie in a single plane. This can
make needle placement challenging when critical structures are close to the
targeted lesion. A real time 3D guidance system would be ideal, but real-time 3
D imaging devices such as CT or MRI scanners, have limited space to perform
the intervention. Safety issues also limit the ability of the physician to guide the
intervention in real time.
With the development of the CSii in-bore automated image guided robotic
system (described elsewhere at this conference), real time MRI and CT guided
intervention is now possible. Further, a system has been developed in which the
physician can plan the entire procedure and optimize as necessary using a virtual
3D system. Early pre-clinical data indicate that this system will dramatically
improve safety and accuracy for MRI- and CT-guided interventional procedures.
We will perform a live demonstration for 3D planning and targeting of a
suspected lesion for an automated robotic intervention.
P069: MINIMIZING HEPATIC TRAUMA WITH A NOVEL LIVER
RETRACTION METHOD DURING ROBOTIC AND LAPAROSCOPIC
GASTRIC CANCER SURGERY, A SIMPLE LIVER-SUSPENSION WITH
GAUZE-SUTURE TECHNIQUE Yanghee Woo, MD, Kazutaka Obama,
MD PhD, Tae-Il Son, MD, Hyung Il Kim, MD, Woo Jin Hyung, MD PhD
Department of Surgery and Robot and Minimally Invasive Surgery Center at
Yonsei University College of Medicine
Introduction: Radical gastrectomy requires prolonged liver retraction for adequate
exposure of the hepatogastric ligament which may lead to unnecesary hepatic
trauma. We offer a new minimally traumatic technique for liver retraction
during totally robotic and laparoscopic radical gastrectomies using simple liver
suspension with gauze-suture technique with a comparison to the established
liver puncture method.
Methods: We retrospectively analyzed the clinical and operative characteristics
along with the patients’ perioperative transaminases of 92 patients who
underwent liver puncture or liver suspension methods during gastric
resection in 2010 and compared the two groups. We excluded other
patients with history of liver diseases, abnormal preoperative liver function
tests, intraoperative aberrant left hepatic artery ligation, postoperative
complications and combined operations. In brief, two 4x4 gauzes were folded
in half and threaded with one double-armed straight needled 2-0 Prolene to
create a 8 cm non-traumatic support for the liver retraction. The ports were
placed as previous described for robotic (Surg Endosc 2009. 23:1204-1211)
and for laparoscopic (Eur J Surg Oncol. 2007. 33:314-319) surgeries. One of
two straight needles and the attached suture-threaded gauzes were introduced
into the intraperitoneum via a 12mm trocar. The straight needle was used to
pierce the anterior abdominal wall directly above the middle of the left lobe
of the liver. Then, the pars flaccida of the hepatogastric ligament was divided
upto the right of the esophageal crus. Two plastic surgical clips (Hem-o-
lock, Weck Pilling, NC) were used to secure the prolene suture to the pars
condensa. The other straight needle with the suture-threaded gauze was then
introduced and passed externally through the abdominal wall just to the right
of the falciform ligament. While the assistant slowly pulled upward on the
two sutures, the two gauzes were brought together by the pars condensa and
stretched to cover the undersurface of the retracted liver creating a V-shaped
liver suspension. The two external sutures are tied together to rest on the
abdominal wall.
53
Poster Abstracts
Results: All liver retraction by either the liver puncture or liver suspension
methods were successfully completed without intraoperative complications.
The patients in the liver suspension group had more non-hepatic comorbidities
than those in the liver puncture group (p=0.029). Other patient
characteristics such as gender, age, and BMI did not differ. There were no
differences between the two groups in the number of robotic (25 vs 20,
respectively) and laparoscopic (24 vs 23, respectively) approaches and total
mean operative times (200.3+66.9 and 214.9+74.4). The preoperative ALT
(17.0+6.0 vs 15.6+4.5) and AST (18.0+3.8 vs. 17.4+ 4.5) levels between
the two groups did not differ significantly. However, the patients in the liver
puncture group had up to 2.4 and 1.6 times greater increase in ALT and AST
levels, respectively with a longer time to normalization than the patients in
the liver suspension group.
Conclusion: We present our simple liver suspension technique to minimize
hepatic trauma from liver retraction during radical robotic and laparoscopic
gastrectomies. Compared to the liver puncture method, our novel liver
suspension method resulted in less hepatic trauma.
P070: DEEP FLEXION KINEMATICS WITH ROBOTIC MODULAR KNEE
ARTHROPLASTY Toshifumi Watanabe, MD, Scott A Banks, PhD, Stefan
Kreuzer, MD, Kevin J Leffers, MD, Takeshi Muneta, MD PhD, Michael A
Conditt, PhD, Jennifer A Jones, BS University of Florida, Gainesville, Florida;
Memorial Bone and Joint Research Foundation, Houston, Texas; Tokyo Medical
and Dental University, Tokyo, Japan; MAKO Surgical Corporation, Fort
Lauderdale, Florida
Introduction In knee arthroplasty, several studies have shown that sparing soft
tissue, particularly the ACL, will allow a patient to retain kinematic function
that more closely relates to normal function versus those with cruciate
substituting implants. Multi-compartment modular knee replacement has a
long history of favorable outcomes. In 1976, Laskin reported good pain relief
and acceptable clinical results after bi-unicondylar knee replacement with a
follow-up of two years. In 1995, Argenson et al. reported on a series of 183
patients who received patellofemoral replacements (PFA) and 104 of which
simultaneously underwent medial unicompartmental replacement (UKA).
84% of patients received satisfactory results although the subset of patients
who received PFA-UKA replacements were not distinguished form the overall
series of patients. While modular knee replacement has had good clinical
results, difficulties exist in achieving precise implantation. Robotic-arm
assisted orthopedic surgery has the potential to achieve levels of accuracy,
precision, and safety not possible with conventional techniques. With the use
of robotic-arm guidance Lonner examined a series of 12 consecutive modular
bicompartmental arthroplasties using discreet components and observed
a mean post-operative Rom at 126 degrees of flexion with statistically
significant improvements in WOMAC and KSS scores at short-term follow-
up. This study analyzed the kinematics of a series of patients that underwent
robotic-arm guided knee arthroplasty with a modular implant system where
both cruciate ligaments were preserved in a uni- or multi-compartment knee
arthroplasty. No prior study has analyzed kinematics with modular knee
arthroplasty.
Materials & Methods We analyzed six osteoarthritic knees that underwent
robotic-arm guided knee arthroplasty with modular implant components. All
surgeries were performed by one surgeon (SWK). The age of the patients at
time of surgery was 60 ± 10 years. The average patient follow-up was 12 ± 3
months. Patients were studied fluoroscopically while they performed daily living
activities (lunge and kneel). Three dimensional kinematics were assessed from
single plane fluoroscopic images using a proven technique from Banks, et al.
Results The average maximum flexion angles observed during kneeling was 127
± 7 degrees and 120 ± 10 during lunging. The mean axial rotation observed
during kneeling was 27 ± 6 degrees and 28 ± 7 degrees during lunging. Mean
rollback observed during kneeling was 19 ± 9mm and 17 ± 7mm during
lunging.
Discussion: The observed deep flexion kinematics related more closely to normal
knee kinematics than previously published results for TKA. Although this study
included a small number of patients, it was observed that robotic-arm assisted
modular knee arthroplasty was indicated to replicate normal knee kinematics in
deep flexion. Further research with a larger subset of patients would strengthen
these findings.
54
P071: ROBOTIC SINGLE-SITE CHOLECYSTECTOMY: THE "SINGLE"
PORT TO THE FUTURE OF SURGERY? FIRST EXPERIENCE FROM
GREECE. Konstantinos M Konstantinidis, MD PhD FACS, Savas C Hiridis,
MD MSc, Periklis S Chrysocheris, MD, Peter C Hiridis, MD, Michael K
Georgiou, MD ATHENS MEDICAL CENTER
Introduction: Laparoendoscopic single-site surgery allows for the performance of
most abdominal procedures with a single small incision and minimal scarring.
The da Vinci Surgical System provides advantages of easy articulation and
improved ergonomics; lately an interesting novel platform was presented by the
manufacturers.
Objective: To present the first experience with the new da Vinci Single-Site
System and assess feasibility, advantages and limitations.
Methods: In February 2011, a single-site robotic surgery program was initiated
in our center. Cholecystectomy was selected as the pilot procedure. All
procedures were completed using the da Vinci Si robotic surgical system. Novel
specialized flexible 5mm analogues of the standard instrument set was used. All
instruments were introduced through Intuitive’s 2cm single site robotic port. A
bed side assistant contributed to gallbladder traction.
Results: Perioperative data were obtained for all patients including demographic
data, operative indications, operative records, length of stay, complications, and
pathologic analysis.
Conclusions: Robotic single site cholecystectomy is feasible and safe. Technology
offers surgeons numerous potential benefits, including: superior identification of
biliary anatomy, meticulous dissection of Calot’s triangle, improved gallbladder
retraction and exposure, better ergonomics with no instrument crowding
and stable visualization of the field. Cost remains a disadvantage for adoption
of more single-site supporters. Additional platform and instrumentation
development will likely simplify robotic single site procedures further as
experience grows.
P072: LESSONS FROM AVIATION: CHECKLISTING IN FRONT OF THE
ROBOTIC SURGICAL ’COCKPIT’. SURGICAL TECHNIQUE CHECKLISTS
FOR INTRAOPERATIVE USE WITH THE DAVINCI SYSTEM. Savas C
Hiridis, MD MSc, Konstantinos M Konstantinidis, MD PhD FACS, Petros
C Hiridis, MD, Fotis Antonakopoulos, MD, Dimitris Mousiolis, MD,
Kouloufakou Kalliopi, MD ATHENS MEDICAL CENTER
Introduction: Modern surgical practice demands the use of evidence-based
guidelines. A Surgical Safety Checklist from WHO has already been
adopted from more than 200 surgical societies and 20 ministries of health
internationally. Laparoscopic and robotic procedures depend on hundreds of
parameters that need to be checked for their safe and efficient completion.
Methods: Using the TILE-PRO system of da Vinci Si we propose a set of
Checklists to use before, and after the procedures. An electronic database of
surgical technique checklists was created based on our standardized techniques
and existing literature. The checklist was read by the surgeon and completed
by the assistants before and after the operations.Results: The process promoted
safety and facilitated standardization of surgical techniques among team
members. It also served educational purposes.
Conclusions: Use of surgical checklists can minimize human error and facilitate
standardization of the techniques. The robotic console offers an excellent
platform for exchange of digital information during surgery. Our small
experience shows that checklists are going to play a central role in the surgical
practice of the next decades.
P073: ROBOTIC TRAINING : LESSONS TO BE LEARNED FROM THE
AERONAUTIC PRACTICE ? J. Hubert, MD, G Herrmann, M Perez, MD,
C Perrenot, C Waked, MD, N Hubert, MD, N Tran, MD 1) Department of
Urology, CHU Nancy-Brabois 54511 VANDŒUVRE les NANCY, FRANCE.
2) School of surgery :UHP-Nancy1, 54500 VANDŒUVRE les NANCY,
FRANCE. 3) Air France company, Paris
Introduction: Robotic surgery is developing exponentially, this raising the
question of surgeons’ training in this new practice. This training requires a
learning course and assessment that could be based on those used by pilots when
qualifying on a new aircraft type.
Material & Methods: Learning and skills on a new aircraft require training that
is highly structured, product of decades of experience in a constant search for
6 TH ANNUAL MIRA CONGRESS May 11-13, 2011
 quality, with an official endorsement by government authorities. It must lead to
a success rate close to 100% given the level of candidates participating in this
training and given economic issues.
Results: This type of training uses CAI (computer assisted instruction), lectures,
fixed simulator training (systems and equipment) and then a flight simulator.
Flights as copilot are allowed after successful completion of the course. These
steps do not exist in surgical training, which remains with a halstedian model,
although many similarities exist. Training in robotic surgery could include steps
like using a simulator that appeared recently on the market and the practicing
surgery on the animal (dry and wetlab).
Conclusion: Training in robotic surgery and assessment of surgeons is still in its
infancy when compared to the training of airline pilots. Many parallels can be
drawn and the robotic surgeons’ training could be more effective if inspired by
the established protocols in aviation.
P074: ROBOTIC-ASSISTED GYNECOLOGIC/ONCOLOGIC SURGERY:
EXPERIENCE OF EARLY CASES IN A SAUDI ARABIAN TERTIARY CARE
FACILITY Ismail A Al-Badawi, MD, Murad Z Al-Aker, MD, Ibtihal Bukhari,
MD, Sarfraz Ahmad, PhD, Jamal Alsubhi, MD King Faisal Specialist Hospital
& Research Center, Riyadh 11211, Saudi Arabia; 2Florida Hospital Cancer
Institute, Orlando, FL 32804, USA
Objective: To report our early experience of case-mix series of robotic-assisted
gynecologic/oncologic surgery in Arabian population from a tertiary care facility,
and to discuss the emergence/growth of robotic surgery in the Middle-East.
Methods: From December 2005 to September 2010, 51 consecutive patients
[benign with complex pathology (BN, n=29) and 22 cases with various
malignancies; i.e., cervical cancer (CC, n=1), endometrial cancer (EC, n=11),
ovarian cancer (OC, n=3), and other cancers including recurrent borderline/
bone metastases (OTH, n=7), underwent robotic-assisted procedures for the
diagnosis, treatment, and management of gynecologic/oncologic diseases at a
single institution using da Vinci® Robotic Surgical System (Intuitive Surgical
System, Inc., Sunnyvale, CA). Data were analyzed for demographics, clinico-
pathologic and peri/post-operative factors, including operative time (OT),
estimated blood loss (EBL), hospital length-of-stay (LOS), and complications
using an intent-to-treat analysis.
Results: Despite continuous growth in the cases performed each year, the
establishment of robotic surgery program at our institution has been rather
challenging due to patient acceptance, public awareness, and administrative
resistance. Mean age of all case-mix was 43±15 years (distribution: BN 39±14,
EC 61±6, OC 36±15, CC 50, and OTH 41±12 years). Body mass index (BMI)
for all case-mix was 30.3±6.9 kg/m2 (distribution: BN 29.7±6.2, EC 34.0±3.6,
OC 20.0±1.7, CC 48, and OTH 30.2±6.2 kg/m2). Histology of most of the EC
cases was endometriod adenocarcinoma. The skin-to-skin OT was: all case-mix
95±43, BN 77±26, EC 156±30, OC 80±35, CC 150, and OTH 79±23 min.
Mean EBL were: case-mix 126, BN 129, EC 177, OC 67, CC 50, and OTH 71
min. Two robotic cases (3.9%) were converted to laparotomy (one each in EC
and BN groups). Mean LOS was 2-days (although most patients were clinically
ready for discharge on day-1, but stayed longer due to various social reasons). Four
cases (7.8%) experienced complications [two in EC (post-op bleeding, post-op
supraventricular tachycardia) and two in BN (wound infection, right common iliac
artery laceration)]. Only 5/22 (22.7%) cancer cases required adjuvant therapy
[EC 2 (radiation), EC 1 (chemotherapy), EC 1 (chemotherapy/radiation) and CC 1
(chemotherapy)]. No peri/post-op related mortality was encountered.
Conclusions: These data suggest that robotic-assisted gynecologic/oncologic
procedures are feasible and satisfactory to our Arabian patient population, and
comparable to the existing literature for Caucasian counterparts in the Western
world. We believe this is the first (and perhaps largest) case-mix series being
reported on the early experience of robotic-assisted surgery for gynecologic/
oncologic cases from Middle-East, and that this approach is gaining acceptance
in our socio-culturally unique part of the world.
P075: ROBOTIC ASSISTED SURGICAL STAGING FOR OVARIAN
CANCER IN A PREGNANT WOMAN Ismail A Al-Badawi, MD, Murad Z Al-
Aker, MD, Wesam Kurdi, MD, Jamal Alsubhi King Faisal Specialist Hospital &
Research Center, Riyadh 11211, Saudi Arabia
Abstract Background: The Robotic assisted surgery is becoming popular among
surgeons as it allows more control with comparable benefits and risks to the
www.mirasurgery.org
standard laparoscopic approach. The use of Robot during pregnancy was
reported earlier and showed to be as safe as laparoscopy. The use of robotic
surgery in ovarian cancer during pregnancy has not been reported before.
To our knowledge this is the first case of Robotic assisted surgical staging for
presumed early ovarian cancer.
Case: 29 years old woman underwent laparotomy for a right ovarian cystectomy,
for presumed endometrioma, the final pathology showed endometrioid
adenocarcinoma Grade I of the ovary in a background of endometriosis. The
patient was referred to a tertiary center and got pregnant in the mean while and
decided to keep the pregnancy. The staging was achieved using Da Vichi robotic
assisted surgery in the mid trimester.
Conclusion: The use of Robotic surgery during pregnancy is feasible at the mid-
trimester; uterine manipulation can be added by the use of fan retractor with no
compromise to complete procedure.
P076: SURGICAL OUTCOMES WITH ROBOTICS AND MORBIDLY
OBESE WOMEN Pamela J Stone, MD, Mohamed Ismaeil, MD, Alexander
Burnett, MD University of Arkansas for Medical Sciences
Introduction: Minimally invasive techniques are increasing in the United States
at the same time as obesity rates are trending upwards. Previous reports have
commented on the effect of BMI on minimally invasive techniques however
there is limited information regarding robotic surgery in the morbidly obese
gynecologic patient. Laparoscopic surgery has been accepted as an appropriate
technique to apply to uterine malignancies as demonstrated with the prospective
LAP study. Robotic surgery may offer an additional tool for these patients in the
standard treatment of endometrial cancer.
Methods: Retrospective evaluation of consecutive cases who underwent robotic
surgery with a BMI ≥ 40 (kg/m2). Foley and uterine manipulation was used
for all cases. Times were extrapolated from medical record for operating room
and console time. Surgeons performed nodes based on grade and depth of
myometrial invasion from operating room inspection.
Results: Over a 2-year time period, 54 morbidly obese women underwent
robotic surgery. The average age was 51 years, and the average BMI was 53
(40-98). The average blood loss was 171ml and the average hospital stay was
1.2 days. There were no conversions due to complications however one case
required a mini-laparotomy to remove an enlarged uterus (696gm), and
one case was abandoned due to airway disease exacerbation at anesthesia
induction. 42 cases were for uterine cancer, 76.2% grade 1 and 23.8% grade
2/3. 9 cases were for endometrial hyperplasia, 2 for cervical dysplasia and 1
for adjuvant treatment. In 46.2%, hysterectomy with BS&O was performed;
additionally 33.3% and 13% had a pelvic and aortic node dissection. One
radical hysterectomy was performed. The average uterine weight was 192 gm.
There were 11 complications with 2 patients have 2 complications--2 blood
transfusion, 3 infections, 3 respiratory problems, 1 incarcerated hernia, 1
cuff hematoma and 1 vaginal cuff bleeding. The average peak airway pressure
was 40.6, average tidal volume 471ml, FIO2 58, ETCO2 36 and an average
OR time 272 min. Of the 32 grade 1 uterine cancers, 53% had a pelvic node
dissection and 9% had an aortic node dissection. 10 patients had grade 2/3
uterine cancers and 70% underwent pelvic node dissection and 40% had
aortic node dissection. The average pelvic and aortic node counts were 12
and 4 respectively. The node count increased as surgeon experience increased
(>10 cases).
Conclusions: As obesity rates increase, gynecologic oncology surgeons are faced
with performing surgery in morbidly obese patients. Our data demonstrates
few complications, a high proportion of staged patients, and feasibility of
the surgical approach. The use of robotic technology affords this benefit
applied to our morbidly obese patients while facilitating the technical
difficulties facing the surgeon and anesthesiologist. With increasing time
and surgeon experience, nodal dissection could be accomplished adequately
without jeopardizing the care of the patient and with acceptable surgical
times. Robotic assistance provides the surgeon with the tool to overcome the
challenges that an extremely obese patient presents. Further feasibility and
outcome studies are needed in this group of patients who are representing a
greater portion of our patients.
55
Poster Abstracts
P077: ROBOTIC EXTRAPERITONEAL ENDOSCOPIC AORTIC
LYMPHADENECTOMY: AN EXPERIMENTAL PIG MODEL Dominique
Lanvin, MD, Monique Bertrand, MD CSTAR (Canadian Surgical Technologies
& Advanced Robotics) Lawson Health Research Institute, London, Ontario,
Canada
Objective of the study: Robotic extraperitoneal endoscopic aortic
lymphadenectomy (REEAL) is an advanced surgical procedure in gynecology
oncology. Lymph node involvement is a crucial prognostic factor in most of the
pelvic cancer. REEAL needs to be evaluated in comparison with laparoscopic
approach. An experimental model is useful for an accurate evaluation of a
new surgical procedure. An animal model is an important part of the surgical
training of the residents and fellows in gynecology oncology . There is no
experimental animal model for REEAL. The goal of this study is to show the
feasibility of REEAL in a porcine model.
Methods & Procedures: Five pigs had a general anesthesia in this study according
the guidelines of the animal care of the laboratories. Two surgeons were
enrolled. The first one is gynecology oncologist trained in advanced laparoscopic
and robotic assisted gynecologic oncology surgery. He is able to perform an
extraperitoneal endoscopic aortic lymphadenectomy by laparoscopy. The
other one is a gynecology oncologist trained in laparotomy only. A REEAL was
performed using a three-arm Da Vinci robot.
Results: The first two pigs were used in order to create the appropriate model for
the trocar’s placement and robot’s docking. Three pigs had a REEAL.
Conclusion: REEAL is feasible in a pig model. This model can be used for
evaluation of the learning curve, safety and accuracy of the REEAL. It remains
an excellent model for the training of the resident and fellow before their first
clinical surgical experience and could decrease the learning curve.
P078: POSTOPERATIVE PAIN MEDICATION REQUIREMENTS
IN PATIENTS UNDERGOING ROBOTICALLY ASSISTED AND
STANDARD LAPAROSCOPIC PROCEDURES FOR NEWLY DIAGNOSED
ENDOMETRIAL CANCER Mario M Leitao, MD, Ginger J Gardner, MD,
Gabriel Briscoe, Priyal Dholakiya, Kevin Santos, Elizabeth Jewell, MD, Nadeem
R Abu-Rustum, MD, Yukio Sonoda, MD, Richard R Barakat, MD, Vivek
Malhotra, MD Memorial Sloan-Kettering Cancer Center
Objective: To compare postoperative pain medication use in patients undergoing
robotically assisted (RBT) and standard laparoscopic (LSC) procedures for
newly diagnosed endometrial cancer.
Methods: All cases with a preoperative endometrial cancer diagnosis scheduled
for RBT or LSC from 5/1/07-6/19/10 were identified. A standardized
postoperative pathway includes routinely offering all patients IV patient-
controlled analgesia (PCA). Various IV PCA data points were retrospectively
abstracted from the electronic medical record for patients who did not require
conversion to laparotomy and had an IV PCA started postoperatively. All
medication doses were converted to equivalent fentanyl doses using institutional
conversion guidelines. The total fentanyl dose was calculated. The total fentanyl
dose was then divided over the total number of hours the patient had access to
the PCA to calculate the hourly fentanyl dose (HFD).
Results: We identified 239 RBT and 244 LSC cases that were not converted
to laparotomy. Baseline patient characteristics were similar. An IV PCA was
used in 206 RBTs (86%) and 217 LSCs (89%) (P=0.2). Ketorolac was given
concurrently in 77% of cases in both groups (P=0.9). Fentanyl was used in
196/206 RBTs (95%) and 195/217 LSCs (90%) (P=0.02). A basal infusion was
used in 3 (1.5%) and 21 (10%), respectively (P<0.001). The median number of
patient attempts was 14 (range, 0-372) for RBT and 21 (range, 0-349) for LSC
(P<0.001). The median number of hours with access to a PCA was 14.9 (range,
0-51) for RBT compared to 16.8 (range, 7-180) for LSC (P<0.001). The median
number of additional medication boluses needed was 1 (range, 1-5) for RBT and
2 (range, 1-6) for LSC (P=0.03). The total fentanyl dose received for RBT cases
was 242.5 ucg (range, 0-2705 ucg) compared to 367.5 ucg (range, 0-2625 ucg)
for LSC (P<0.001). The median HFD was 16.7 ucg (range, 0-51 ucg) for RBT
compared to 22.7 ucg (range, 0-132.4 ucg) for LSC (P=0.01). Simultaneous
multiple regression analysis further demonstrated that RBT was independently
associated with a lower total fentanyl dose compared to LSC (P=0.04).
Conclusions: The use of the robotic platform is independently associated with
significantly lower postoperative pain medication requirements compared to
standard laparoscopy.
56
P079: VAGINAL CUFF DEHISCENCE AFTER ROBOTICALLY ASSISTED
PROCEDURES REQUIRING A COLPOTOMY Mario M Leitao, MD, Ginger
J Gardner, MD, Gabriel Briscoe, Elizabeth Jewell, MD, Nadeem R Abu-
Rustum, MD, Carol L Brown, MD, Dennis S Chi, MD, Yukio Sonoda, MD,
Douglas A Levine, MD, Richard R Barakat, MD Memorial Sloan-Kettering
Cancer Center
Objective: To determine the rate of postoperative vaginal cuff dehiscence in
patients undergoing robotically assisted procedures that require colpotomy.
Methods: We identified all cases undergoing a robotically assisted procedure for
various indications from 5/15/07 to 9/29/10. From this cohort, we identified
patients who required a colpotomy for procedure completion and were not
converted to laparotomy. Clinical data were extracted from the electronic
medical record. Various additional procedures were performed in many cases,
but we did not include these other procedures in our analyses. It is standard
practice at our institution to close the vagina primarily using a running 0-vicryl
suture as would be done via laparotomy and encompassing at least 1 cm of
vaginal mucosa. No other vaginal closure devices or disposables are used.
Results: We identified 484 robotically assisted cases that required a colpotomy as part
of their procedure and were not converted to laparotomy. The median age was 58
years (range, 27-89). The median BMI was 27.6 kg/m2 (range, 16.2-66 kg/m2).
None of the cases involved a vaginal approach. A simple hysterectomy was performed
in 441 cases (91%), radical hysterectomy in 30 (6%), simple trachelectomy in 4
(<1%), radical trachelectomy in 8 (2%), and radical parametrectomy in 1 (<1%)
case. The median time to close the vaginal cuff was 19 minutes (range, 2-108).
The indication for surgery was malignancy in 355 (73%) of 484 cases. Vaginal cuff
dehiscence was diagnosed in 4 cases (0.8%). These 4 cases were all performed in the
setting of malignancy, and the BMI was <30 kg/m2. All 4 dehiscences were small
and partial, and none had bowel evisceration. Spontaneous dehiscence occurred in
3 (75%) of the 4 cases and were allowed to close without surgical intervention. One
of the 4 dehiscences occurred after intercourse prior to 6 weeks from surgery and
required a single suture under anesthesia.
Conclusions: Vaginal cuff dehiscence is a rare event (<1%) after robotically
assisted procedures and can be avoided if proper surgical techniques are used.
The majority are partial, and can be managed conservatively.
P080: INTEGRATION AND TRAINING OF ROBOTICALLY-ASSISTED
SURGERY IN A GYNECOLOGIC ONCOLOGY FELLOWSHIP PROGRAM
Mario M Leitao, MD, Ginger J Gardner, MD, Gabriel Briscoe, Kevin Santos,
Elizabeth Jewell, MD, Carol L Brown, MD, Dennis S Chi, MD, Richard R
Barakat Memorial Sloan-Kettering Cancer Center
Objective: To assess the feasibility and outcomes of integrating robotically-assisted
surgery in a gynecologic oncology fellowship program.
Methods: We identified all cases planned for a robotically-assisted procedure from
5/15/07 to 9/28/10. Various procedures for benign and malignant gynecologic
indications were performed during this time period. Time points were prospectively
captured intraoperatively as part of an ongoing quality assessment program. All
cases were performed with a gynecologic, surgical, or urologic oncology fellow.
Fellow time spent on the surgeon console performing some or all of the procedure
was captured intraoperatively for cases that were not converted to laparotomy.
Total operating room time (ORT) was determined from patient arrival to exit in
the operating room. Total operating time (OT) was determined from skin incision
to completion of skin closure. Time periods were compared as follows: first year
(Y1)=2007/2008, second year (Y2)=2009, third year (Y3)=2010. Complications
were assessed within 30 days of surgery. Appropriate statistical tests were used.
Results: There were 775 cases planned for a robotically-assisted procedure during
our study period; 162 (Y1), 331 (Y2), and 282 (Y3). The median age, median
BMI, and malignancy as an indication for surgery was similar for all 3 time periods
(P=NS). Conversion to laparotomy occurred in 23/162 (14%) Y1 cases, 29/331
(9%) Y2 cases, and 18/282 (6%) Y3 cases (P=0.02). In cases not converted to
laparotomy, fellows sat at the surgeon console in 17/139 (12%) Y1 cases, 151/302
(50%) Y2 cases, and 183/264 (69%) Y3 cases (P<0.001). The median ORT was
298 minutes (range, 116-670) for Y1, 249 minutes (range, 104-659) for Y2, and
225 minutes (range, 79-584) for Y3 (P<0.001). The median OT was 218 minutes
(range, 58-533) for Y1, 169 minutes (range, 34-562) for Y2, and 148 minutes
(range, 39-496) for Y3 (P<0.001). In the cases not converted to laparotomy,
intraoperative and postoperative complications occurred in 25/139 (18%) Y1
cases, 27/302 (9%) Y2 cases, and 15/264 (6%) Y3 cases (P<0.001).
6 TH ANNUAL MIRA CONGRESS May 11-13, 2011
 Conclusions: Robotically-assisted surgery can be safely and efficiently integrated
into a gynecologic oncology fellowship program. Despite significant increased
fellow participation on the surgeon console, there were continued overall
improvements in ORT, OT, rate of conversion, and complication rates.
P081: COLPOTERES SUSPENSION PROCEDURE John S Missanelli, DO
Grossmont Obstetrics and Gynecology
A unique procedure to restore pelvic floor prolapse is embodied in the technique
of the colpoteres/cervicoteres suspension procedure. With robotic assisted
laparoscopy, the round ligaments are attached to the angles of either the cervical
stump or the vaginal vault, at the time of robotic total or supracervical hysterectomy,
or as a primary procedure if hysterectomy has been previously done. The suspension
is then reinforced with a Prolene mesh that has been"sandwiched" between coverings
of Bovine integument, and covered with posterior parietal peritoneum. Pelvic
Organ Prolapse Quotient Scores are assigned to the patient before, immedately post
operatively and at six weeks and six months. In a series of twenty-five cases to date,
there has been restoration of the POP-Q to 0 or 1 with no recurrance of prolapse.
The MSN Procedure(Missanelli, Steele, Naponic) is offered as competitive and a
proven alternative to robotic assisted laparoscopic sacrocolpopexy.
P082: INTRODUCTION OF ROBOTIC TECHNOLOGY FOR
HYSTERECTOMY: ANALYSIS OF FEASIBILITY AND COMPLICATION
RATES DURING THE FIRST 4 YEARS OF USE Sidonia-Maria Saceanu,
Resident Doctor, Nicola Pluchino, Dr, Letizia Freschi, Dr, Vito Cela,
Dr, Marcela Goga, Dr, Lavinia Dobrescu, Dr, Alexandru Goganau, Dr,
Andrea Genazzani, Professor Department of Reproductive Medicine and
Child Development Division of Gynecology and Obstetrics University of
Pisa,Italy,Department of Gynecology and Obstetrics II, University Hospital
Craiova,Romania
Objective: To determine the prevalence, indications, success rate and
complications in performing hysterectomy (simple and radical) using robotic
technology.
Study Design: Retrospective study of 59 hysterectomies performed from
November 2007 through December 2010 (4 years) at Cisanello Hospital - Ob/
Gyn - University of Pisa, Pisa. Data included diagnosis, patient characteristics,
surgical procedure (duration, type, blood lost), and hospitalization days and
complications rate.
Patients: 59 women (35-75 years) were analyzed. All patients received a robotic-
assisted laparoscopic hysterectomy (simple or radical) from September 2007 to
December 2010 in Cisanello Hospital - Ob/Gyn - University of Pisa, Pisa.
Intervention: Robotic-assisted laparoscopic hysterectomy using Da-Vinci System
Results: In 2007 were performed 2 hysterectomies, in 2008 the number
of procedure increased to 8 hysterectomyes; in 2009 we performed 19
hysterectomies and in 2010, n°30 hysterectomies. The percentage increased of
30-65% hysterectomies at year. We performed 19 hysterectomies for cervical
cancer, 22 hysterectomies for endometrial cancer and 18 hysterectomies for
uterus fibromatosis. Blood loss during surgery was 50-175 cc without significant
changes in hemoglobin value. Hospitalization period was 2 days. Patients had an
uneventful postoperative course.
Conclusions: Route of hysterectomy changed significantly after the introduction of
robotic technology. Open hysterectomy was associated with significantly higher
complication rates than robotic hysterectomies, more blood lost, more days of
hospidalization. Robotic hysterectomy is a recommended intervention in variety
of gynecologic conditions including: abnormal excessive bleeding, fibroids,
endometrial and cervical cancer. The daVinci surgical system provides surgeons
with enhanced true 3-D vision, ergonomic comfort of surgical manipulation and
unprecedented precision of tissue handling. In this specific area of hysterectomy
Da Vinci System, decreased blood loss, increased recovery time, greatly reduced
post-operative pain, quicker return to daily activities, improved cosmesis.
P083: ROBOTIC SURGICAL REMOVAL OF BLADDER ENDOMETRIOSIS
-THE NEW GOLD STANDARD? Sidonia-Maria Saceanu, Dr, Nicola
Pluchino, Dr, Letizia Freschi, Dr, Alexandru Handabureac, Dr, Ayed Kamal,
Dr, Alexandru Goganau, Dr, Vito Cela, Dr, Andrea Genazzani, Professor
Department of Reproductive Medicine and Child Development Division of
Gynecology and Obstetrics University of Pisa,Italy,Department of Gynecology
and Obstetrics II, University Hospital Craiova,Romania
www.mirasurgery.org
Objectives: To demonstrate the safety, utility and feasibility of robot-assisted
laparoscopic treatment of bladder endometriosis.
Materials & Methods: Two women, aging 30-33, with a 4-5 cm bladder mass on
pelvic ultrasonography and history of infertility/pelvic pain were enrolled.
Cystoscopy biopsy in one case revealed endometriosis. After hormonal medical
therapy was performed excision of endometriosis bladder nodule with partial
cystectomy with robotic assistance (da Vinci) in 2010.
Results: Robotic-assisted with da Vinci system partial cystectomy with
concomitant excision of endometrial nodules from peritoneum was performed
in a mean time of 150 min. The blood lost was 50cc. Patients had an uneventful
postoperative course and hospital stay. Follow-up imaging revealed no bladder
extravasation or fistula formation.
Conclusions: Endometriosis is the presence of endometrial glands and stroma
outside of the uterine cavity. Robotic-assisted laparoscopic partial cystectomy for
endometriosis can be safely performed and provide advantages in the management
of women with severe endometriosis secondary to 3-dimensional visualization,
decreasing surgeon’s fatigue and hand tremors and improving surgical precision.
P084: ROBOTIC ASSISTED LAPAROSCOPIC ABDOMINAL CERCLAGE: A
NOVEL APPROACH Donna Brown, MD, Frank Craparo, MD, Mark Shahin,
MD, Larry Barmat, MD Abington Memorial Hospital, Abington, PA
Abdominal cerclage has been shown to be of benefit in the outcomes of patients
who fulfill the criteria for placement, ie failed cervical cerclage or lack sufficient
length of cervix inside the vagina. However with traditional abdominal cerclage,
comes the risk and complications associate with laparotomy. The patients had
to spend days in the hospital and had weeks of recovery. In addition the patient
had to then undergo a second laparatomy for delivery. As technology progressed,
gynecologists became more adept with laparoscopy and more recently with robotic
surgery. Surgeries previously requiring lengthy hospital stays could be done with
small incisions and require little to no hospital stay. With advent of laparoscopy
and increasing number of physicians skilled in advanced laparoscopic skills, the
idea of performing an abdominal cerclage laparoscopically became feasible.
The patient is a 28 year old G4P0130 with a significant past obstetrical history
of two prior first trimester losses and two second trimester losses, the latter of
which was despite the placement of a transvaginal McDonald cervical cerclage.
After evaluation by the Maternal Fetal Medicine group she was determined to
be a candidate for abdominal cerclage. The patient was counseled that in the
literature there are several case reports of abdominal cerclage being performed
laparoscopically and with the use of the da Vinci robot. At this institution, one
prior robotic assisted abdominal cerclage had been successfully placed. The patient
decided on a minimally invasive approach.
The trochars were placed as in typical for pelvic surgery with the aid of the da
Vinci robot. A uterine manipulator was also used. Using blunt and sharp dissection
the bladder flap was created. In the prior abdominal cerclage, the Maryland was
used to pierce a hole in the broad ligament in an anterior to posterior fashion.
Due to the patient’s anatomy, this technique was not feasible. The bladder flap
was then extended sharply to the level of the cervicovaginal junction and the
width extended so that the pulsation of the uterine arteries could be visualized.
A segment of 2-0 vicryl was attached to the mersilene tape. The needle was
straightened and the combination was placed on the inside of the uterine arteries.
The excess was cut off and the mersilene tape tied on the posterior aspect of the
uterus. Excellent hemostasis was noted with minimal blood loss. The patient was
able to go home the same day.
The patient subsequently became pregnant. Her pregnancy was complicated by
gestational diabetes. She delivered a viable male infant in the breech presentation
at a scheduled 39 week cesarean section. At the time of delivery, no adhesions
were noted and the cerclage was found to be intact in the correct position. The
cerclage was left in place for future pregnancies.
This case demonstrates that an abdominal cerclage can be successfully placed
using the da Vinci robotic system. Case reports similar to this are increasing in the
literature but still more information is needed to determine the ideal technique
and long term outcomes.
P085: ROBOT-ASSISTED VERSUS OPEN RADICAL HYSTERECTOMY: A
COMPARISON OF ONE SURGEON’S OUTCOME. Bilal M Sert, MD, Vera
Abeler, MD PhD The Norwegian Radium Hospital
57
Poster Abstracts
Objective: To compare internally one surgeon´s abdominal radical hysterectomy
(ARH) and robot-assisted laparoscopic radical hysterectomy (RALRH) results.
Methods: As an internal control, we selected 26 ARH cases performed by the
same surgeon (BMS) and compared his 43 RALRH cases. We compared the
clinical characteristics, perioperative results and mean 3 years outcomes.
Results: The study and control groups had similar characteristics ( age, body mass
index, stage). The RALRH group had a statistically significant advantage for
estimated blood loss (83 ml versus 595 ml. p<0.0001) and hospital stay (4 days
versus 9 days p<0.001). At the mean 3 years follow-up the recurrence rate is
higher in RALRH group while only one death occurred in each group.
Conclusions: We present the results of RALRH and ARH performed by one
surgeon. With only a 43 cases experience, RALRH offers the benefits of
minimally invasive surgery and does not compromise both clinical and pathologic
outcomes. The recurrence rate is 11.1% after the mean 3 years follow-up.
P086: MORBID OBESITY OUTCOMES IN ROBOTIC GYNECOLOGIC
SURGERY Taryn Gallo, MD, Masoud Azodi, MD Yale New Haven Health /
Bridgeport Hospital
Study Objective: To assess perioperative outcomes in morbidly obese patients
undergoing robotic hysterectomy.
Methods: A retrospective cohort study was performed for patients who
underwent robotic hysterectomy from September 2006 to June 2010 for
both benign and malignant indications. Patient demographics, intraoperative
outcomes, rates of complication, readmission, and reoperation were compared
for those patients having a body mass index (BMI) of 35 kg/m2 or greater with
those whose BMI was less than 35 kg/m2.
Results: Of 380 patients who met inclusion criteria, 150 (39%) women were
morbidly obese with a BMI of 35 kg/m2 or greater. In the morbidly obese
group, the mean BMI was 42.6 kg/m2 vs. 27.2 kg/m2 in the comparison
group. There were no significant differences between the groups in terms
of estimated blood loss, uterine weight or length of hospital stay (138 vs.
123 mL, P = .16; 210 vs. 224 gms, P = .54; 1.3 vs. 1.4 days, P = .31,
respectively). There were no significant differences in complication,
readmission, and reoperation rates between the two groups. There was one
conversion in the morbidly obese group.
Conclusions: Robotic hysterectomy can be performed safely in morbidly obese
patients, with surgical outcomes and complication rates similar to those for non-
morbidly obese patients.
P087: INCIDENCE OF VAGINAL CUFF DEHISCENCE WITH ROBOTIC
HYSTERECTOMY: AN ANALYSIS OF 500 CASES Taryn Gallo, MD, Masoud
Azodi, MD Yale New Haven Health / Bridgeport Hospital
Study Objective: To assess the rate of vaginal cuff dehiscence in patients
undergoing robotic-assisted laparoscopic hysterectomy (RALH).
Methods: A retrospective analysis of 500 patients who underwent robotic
hysterectomy from September 2006 to August 2010 for both benign and
malignant indications.
Results: There were 2 cases (0.4%) of vaginal cuff dehiscence. Intercourse was
the triggering event for the first case, which occurred 85 days after RALH. The
second case occurred 30 days after RALH with the triggering event of straining
during defecation. Both cases were promptly repaired vaginally with one
requiring laparoscopic assistance.
Conclusion: Vaginal cuff dehiscence with RALH is similar to that reported in the
literature for laparoscopic hysterectomy. In our study, robotic hysterectomy is
not associated with an increased risk of cuff dehiscence.
P088: USE OF INTRAUTERINE MANIPULATOR AND ITS EFFECT ON
LYMPHOVASCULAR SPACE INVASION IN ROBOTICALLY ASSISTED
ENDOMETRIAL CANCER STAGING Rhoda A Raji, MD, Karim ElSahwi,
MD, Charlene Hooper, MD MPH, Elena Ratner, MD, Dan-Arin Silasi, MD,
Peter E Schwartz, MD, Thomas J Rutherford, MD PhD, Masoud Azodi, MD
Yale-New Haven Hospital, New Haven, CT, 06520 , USA.
Objectives: To evaluate the association between the use of a uterine manipulator
and lymphovascular space invasion (LVI) in robotically assisted staging for
endometrial cancer.
58
Methods: Retrospective chart review of 77 cases of endometrial cancer who
underwent robotically assisted staging between September 2006 and September
2010. Data abstracted included patient demographics, operative notes, and
pathology reports. Data were analyzed using chi-square test for the presence of an
association between the use of a uterine manipulator and LVI. Fisher exact test was
used for small numbers. Logistic regression model was used to confirm results.
Results: Seventy seven cases were included in the study. All had robotically
assisted total laparoscopic hysterectomy bilateral salpingoopherectomy and
retroperitoneal lymph node dissection for endometrial cancer. 18 cases were
completed with the use of a uterine manipulator (Group A). 59 cases were
completed with the use of a sponge stick to delineate the vaginal fornix (Group
B). Seven cases in Group A had LVI compared to 5 cases in Group B (P=0.298).
Lymph node metastasis was found in 1cases in Group A compared to 5 cases in
Group B (P=1.00). Positive washing was found in 1cases in Group A compared
to 6 cases in Group B (P=1.00). In a logistic regression model, none of the above
variables was independently associated with the use of a manipulator.
Conclusion: The use of a uterine manipulator in robotic assisted surgical staging
for endometrial cancer seems not to be associated with an increased incidence of
lymphatic vascular spread of malignant cells.
P089: SINGLE PORT HYSTERECTOMY: CONVERTING FROM SINGLE
PORT LAPAROSCOPY TO SINGLE PORT ROBOTIC: THE GREEK
EXPERIENCE OF INTRODUCING INNOVATIVE SURGERY IN A
FINANCIAL CRISIS ENVIRONMENT Stefanos Chandakas, MD MBA PhD,
John Erian, FRCOG Iaso Group of Hospitals, Athens, Greece and Attikon
University Hospital, Athens, Greece
Minimally invasive surgery has influenced the techniques used in gynaecology,
with an overall minimisation of complications and increased patient satisfaction.
The study objective is to demonstrate the safety and feasibility of Single Port
(SP) Total Laparoscopic Hysterectomy and ther issues that need to be addressed
before converting to Single Port Robotic Hysterectomy
Methods & Procedures: Retrospective, descriptive, non randomized study
Setting: Iaso Hospital and Attikon University Hospital, Athens, Greece
Patients: 22 patients underwent SP Total Laparoscopic Hysterectomy between
October 2008 and January 2011. Indications included 88% Dysmenorrhoea and
12% Large Fibroids Uteri
Main Results: Duration of operation and of hospital stay, safety (morbidity and
mortality), and patient satisfaction were assessed .Estimated blood loss was 110
ml (range 165-300 ml) Intraoperative complications: 0% vascular injuries and
0% nerve or ureter injuries. Early postoperative morbidity included no major
complications, 0% bladder infection and dysfunction and 0.22% of incision
infection. 51% of patients were discharged to home the same day with an average
length of stay for these patients of 14 hours .The compared cost with traditional
laparoscopic hysterectomy was reduced by 22%, mainly due to the use of
reusable instruments and just one single use Single Port Special Trocar.
Conclusions: Single port Total Laparoscopic Hysterectomy seems to be a safe
and more cost effective alternative to traditional Laparoscopy. Our unit will
introduce the Robotic approach once the DaVinci Robotic system will get FDA
licensing for Single Port Surgery. Surgical time, safety and feasibility, additional
costs, complexity and combination of procedures will be addressed before
moving to the new robotic approach.
P090: ENDOMETRIAL CANCER AND ROBOTIC SURGERY: OUR
EXPERIENCE Mario Villa, MD, Michela Teruzzi, MD, Ciro Sportelli,
MD, Francesca Fei, MD, Giovanna Caspani, MD, Sara Sacco, MD, Antonio
Pellegrino, MD Azienda Ospedaliera Ospedale Provinciale di Lecco, Italy
Introduction: Endometrial cancer is the most common female malignancy (6%)
(1). Robotic-assisted laparoscopic hysterectomy seems to overcome standard
laparoscopy problems (2). Feasibility and safety are objectives of our analysis.
Methods & Procedures: Between January 2010 to December 2010, twelve patients
with diagnosis of early endometrial cancer, were enrolled in our study; pre-
operative work-up included clinical check, ultrasound scan, office hysteroscopy
with endometrial biopsy, pelvis and abdomen MRI and chest radiography.
They underwent robotic surgery (total hysterectomy with bilateral salpingo-
oophorectomy) at Manzoni Hospital, Lecco, Italy. Frozen section is used to
define who needs pelvic staging. Three patients received pelvic node dissection.
6 TH ANNUAL MIRA CONGRESS May 11-13, 2011
 Results: Twelve consecutive patients were submitted to robotic extrafascial
hysterectomy with bilateral salpingo-oophorectomy for early stage endometrial
cancer. Mean patient age was 58,6 yeras (range 49-66), BMI was 26,72 kg/m2
(21,45-34,67), mean operating time was 168 minutes (80-310), mean docking
time was 8,83 minutes (4-17), mean blood loss was 20 mL (10-150), mean
hospital stay was 1,2 days (1-2). No procedure was converted to laparotomy. No
complications are reported.
Conclusions: Treatment of early-stage endometrial cancer is surgery: total
hysterectomy, BSO and staging, if necessary. Laparoscopic technique is standard
procedure and it proves as safe and feasibile as laparotomy (3-4) with longer learning
curve. Da Vinci approach offers shorter learning curve (5) with technical advantages
(three dimensional visualization, increased degrees of motion, improved dexterity,
elimination of tremor, surgeon comfort). Many study were published about Robotic
surgery, comparing it with laparoscopy (7) and laparotomy (6-8). With less blood
loss, shorter hospital stay, robotic surgery seems to be the best approach; operative
time was significantly longer in the robotic group when compared with open-
surgery, but lower morbidity, feasibility and safety justify its use.
Although little series, our results confirm that robotic procedure could be
standard approach for treatment of early stage endometrial cancer.
Bibliography:
1) Jemal et al, Cancer statistics 2007. CA Cancer J Clin. 2007; 57: 43-66
2) Kho et al, Robotic hysterectomy: tecnique and initial outcomes, Am. J Obstet
and Gynecol 2007; 197: e1.113-4
3) Kornblith et al. QOL of patients with endometrial cancer undergoing
laparoscopic international federation of gynecology and obstetrics staging
compared with laparotomy: GOG study. J Clin Oncol 2009;27:5337-42
4) Walker et al. Laparoscopy compared with laparotomy for comprehensive
surgical staging of uterine cancer: GOG study LAP 2. J Clin Oncol
2009;27:5331-36
5) Cho et al, Robotics and Gynecologic Oncology: review of the literature, J
Minim Invasive Gynecol 2009;16(6):669-81
6) Gehrig PA et al, What is the optimal minimally invasive surgical procedure
for endometrial cancer staging in the obese? Gynecol Oncol. 2008; 111:41-5
7) Veljovich et al robotic surgery in gynecologic oncology: program initiation
and outcomes after the first year with comparison with laparotomy for
endometrial cancer staging. Am J Obstet and Gynecol. 2008; 198:679.e1-e.10
8) De Nardis et al Robotically assisted laparoscopic hysterectomy versus total
abdominal hysterectomy and lymphadenectomy for endometrial cancer. Gynecol
Oncol. 2008; 111:412-7
P091: LAPAROSCOPIC AND ROBOTICALLY ASSISTED
HYSTERECTOMY. OUR EXPERIENCE IN A SERIES OF 8 CONSECUTIVE
CASES. Konstantinos P Mirillas, MD, Petros C Hiridis, MD, Bisbikis Dimitris,
MD, Savas C Hiridis, MD MSc, Perikles S Chrysocheris, MD, Konstantinos M
Konstantinidis, MD PhD FACS ATHENS MEDICAL CENTER
Objective: To assess robotically assisted laparoscopic hysterectomy in patients with
benign conditions in comparison to conventional laparoscopic hysterectomy.
Study Design: Retrospective study of 42 patients undergoing robotic (n=8) or
laparoscopic (n=34) hysterectomy. Data included uterus weight, total vs subtotal
hysterectomy, pathological findings, skin-to-skin operative time, estimated
blood loss, complications, and postoperative hospitalization length. All
hysterectomies were performed by the same surgeon.
Results: All robotic hysterectomies were completed with no conversion to
laparotomy. The average uterus weight was 415g respectively.The mean and
range of the operating time was 145min for robotic and 115 min for laparoscopic
hysterectomy. The estimated blood loss was less in the robotic method, due to
the effective combination of monopolar and bipolar electrocoagulation.
Conclusion: Robotic-assisted hysterectomy (RAH) is feasible and safe for women
with benign uterine pathology.
P092: ROBOTIC REPAIR AND REINFORCEMENT WITH PERMACOL®
OF GIANT HIATAL HERNIA IN AN INFANT Eun Young Chang, MD, Jae
Ho Shin, MD, Hye Kyung Chang, MD PhD, Jung-Tak Oh, MD PhD, Seok Joo
Han, MD PhD Department of Pediatric Surgery, Severance Children’s Hospital,
Yonsei University College of Medicine, Seoul, Korea
Introduction: The recurrence rate in laparoscopic hiatal hernia repair is reported
to be higher than in conventional open method. This high recurrence rate may
www.mirasurgery.org
be attributable to the difficulty in making secure ties when using laparoscopic
method. To prevent recurrence and maintain the benefit of minimally invasive
surgery, we performed a robotic repair and reinforcement with porcine dermal
collagen implant (Permacol®) for an infantile giant hiatal hernia.
Methods & Procedures: A three-month-old 6.9 kg boy with an incidental hiatal
hernia was presented for further evaluation and treatment. An esophageal
contrast study and chest CT depicted near total gastric herniation through a
giant hiatal defect. After verification of pathologic gastroesophageal reflux
with 24-hr esophageal pH monitoring, robotic repair of the hiatal hernia using
da Vinci® system was performed. Two thirds of the stomach was herniated to
large hiatal defect. After repairing the defect using interrupted non-absorbable
sutures, the diaphragmatic crura was reinforced using the Permacol® patch.
Nissen fundoplication was also done. Total operation time was 340 minutes, and
the console time was 270 minutes.
Results: The patient was discharged in fifth day after the operation without any
complications. No evidence of recurrence was observed during the follow-up
period.
Conclusions: Robotic repair and reinforcement of diaphragmatic crura with
porcine dermal collagen implant (Permacol®) for an infantile hiatal hernia is
a safe and feasible method to prevent recurrence and maintain the benefits of
minimally invasive surgery.
P093: THE EXPERIENCE OF THE 2ND UROLOGY DEPARTMENT AT
HYGEIA HOSPITAL IN ROBOTIC SURGERY Alexandros Mokakos, MD,
Spiridon Martinis, MD, Emanuel Panagiotou, MD 2nd Department of Urology,
Hygeia Hospital, Athens Greece
Purpose: To report the experience of 2nd Urology department of Hygeia Hospital
in Urological Robotic Surgery.
Methods & Procedures: Since June 2007, over 300 patients underwent a various
number of urological robotic surgeries (radical prostatectomies, simple or
radical nephrectomies, partial nephrectomy, radical and partial cystectomy,
pyeloplasty, kidney cyst, varicocele, BPH and a rare case of a giant multilocular
cystedenoma of the prostate).
Results: The radical prostatectomies (275) were performed with transperitoneal
approach. Two cases had to be open. The average surgical time, blood loss,
hospital stay and catheter time was 168 min, 142 ml, 2.5 days and 12 days
respectively. 85 % had good erectile function in the first year and 98 %
was continent. Complications : 1 ureter injury, 2 post – OR bleeding, 1
thrombosis and 1 pulmonar embolie. The radical nephrectomies (11) were done
transperitoneally and no case was transformed to open. The mean age OR-time,
tumor size, blood loss and hospital stay was 68 yrs, 158 min, 6.1 cm, 183 ml
and 2.4 days respectively. In the partial nephrectomies (7) the average OR-time
was 191 min, the mean ischemia time 25.6 min and the mean hospital stay 2.9
days. Duration of the pyeloplasties was 120 – 180 min with 1-2 days hospital
stay and without complications. 12 patients underwent radical cystectomy and
ileal conduit urinary diversion or ureterostomies. The bowel part was done
open in only two patients. OR duration was 240 – 415 min, hospital stay 6 – 11
days without any major complications. Adenoma enucleation for benign prostate
hyperplasia occurred in 10 patients. Duration was 100 – 180 min, hospital stay
2 – 3 days and catheter indwelling time 6 – 7 days. One patient with a giant
multilocular cystadenoma of prostate underwent radical prostatectomy.
Conclusions: In our department almost all the cases are done robotically with Da
Vinci - S system, with safety, success and great efficacy.
P094: ROBOTIC-ASSISTED RADICAL PROSTATECTOMY IN MEN OVER
75 YEARS OF AGE. SURGICAL, ONCOLOGIC AND FUNCTIONAL
OUTCOMES. Apostolos P Labanaris, MD PhD, Vahudin Zugor, MD PhD,
Jorn H Witt, MD PhD Department of Urology and Pediatric Urology - Prostate
Center Northwest, St. Antonius Medical Center, Gronau, Germany
Introduction: The aim of this study is to evaluate the surgical, oncologic and
functional outcomes in men ≥ 75 years of age undergoing robot-assisted radical
prostatectomy (RARP).
Methods & Procedures: The records of N=2000 men who underwent RARP
at a certified robotic institute from February 2006 to April 2010 were
retrospectively reviewed. A total of N=45 (2,25%) were ≥ 75 years of age.
A comparison was performed between the overall patient cohort and the
59
Poster Abstracts
aforementioned patients. The parameters analyzed included: age, body-mass
index (BMI), prostate weight, PSA values, bilateral neurovascular bundle (NVB)
preservation, estimated blood loss, minor (Clavien’s grade I–IIIa) and major
complications (Clavien’s grade IIIb-IVa), skin-to-skin operative time, length
of catheterisation, Gleason score, pathologic stage, percentage of PCa found in
the prostate specimen, positive margin status, continence (defined as no pad
use) and potency (defined as erections sufficient for penetration with or without
phosphodiesterase inhibitors)
Results: A statistical difference of the parameters analyzed was not observed.
The median BMI was 26.7 kg/m2 / 26.9 kg/m2, the median prostate weight
was 56.1 gr. / 52.8 gr. and the median PSA value was 10.3 ng/ml / 9.3 ng/ml.
A bilateral NVB preservation was performed in 65.7% / 51.1% of cases and
the estimated blood loss was 160ml / 131ml. Minor complications were noted
in 11.4% / 15.5% of cases and major in 1.3% / 2.2%. The median operative
time was 156 min / 143 min and the length of catheterisation was 5.5 days /
6.1 days. A Gleason score < 7 was noted in 42.8% / 37.3%, a Gleason score 7
in 47.7% / 51.1% and a Gleason score > 7 in 9.5% / 11.6%. A organ-confined
disease in was noted in 73.5% / 68.8%, extraprostatic extension in 25.2% /
31.2% and a positive surgical margin status was encountered in 8.9% / 11.1%
of cases. The percentage of PCa found in the prostate specimen was 16.1% /
17.8%. At 12 months, 92.8% / 86.9% were continent and 66.2% / 39.6 %
(p<0.001) of preoperative potent patients who underwent NVB preservation
were potent.
Conclusions: Our findings suggest that RARP in patients ≥ 75 years of age is a
safe surgical procedure with limited complications and excellent oncologic and
continence outcomes. Even so radical prostatectomy in patients older than 75
years should be limited to a selected collective with a good health status and
an individual life expectancy of more than 10 year to achieve the oncological
advantages of the surgery.
P095: EVALUATION OF SURGICAL MARGIN STATUS IN PATIENTS
UNDERGOING ROBOTIC-ASSISTED RADICAL PROSTATECTOMY FOR
LOW, INTERMEDIATE, AND HIGH-RISK PROSTATE CANCER. Apostolos
P Labanaris, MD PhD, Vahudin Zugor, MD PhD, Jorn H Witt, MD PhD
Department of Urology and Pediatric Urology - Prostate Center Northwest, St.
Antonius Medical Center, Gronau, Germany
Introduction: Although the past years robot-assisted radical prostatectomy
(RARP) has become profoundly popular, some urologists remain sceptic
regarding the lack of tactile sensation and subsequently a possible increase of
positive surgical margins (PSM). The objective of this study is to evaluate the
surgical margin status in patients undergoing RARP for low, intermediate, and
high-risk prostate cancer (PCa).
Methods & Procedures: The records of N=2000 men who underwent RARP
at a certified robotic institute from February 2006 to April 2010 were
retrospectively reviewed. A total of N=125 patients were identified as having a
low risk PCa (Gleason ≤ 6, PSA < 10 ng/ml, T1c-T2a), N=825 an intermediate
(Gleason 7, PSA 10–20 ng/ml, T2b) and N=1050 a high risk PCa (Gleason >7,
PSA >20 ng/ml, >T2b). The parameters analyzed included PSM rates according
to low risk PCa, intermediate risk PCa, high risk PCa and pathologic stage.
Patients with cT3 disease or Gleason score ≥ 8 or PSA > 20ng/ml underwent
wide excision of the neurovascular bundles. PSM were defined as cancer at the
inked resection margin.
Results: The overall PSM rate was 8.1% (N=162 patients). PSM was evident in
N=1 (0.8%) of low risk, N=27 (3.2%) of intermediate risk and N=134 (12.7%)
of high risk PCa patients. According to pathologic stage, PSM were noted in
3.1% of pT2 cases (45 of 1484 pT2 patients), 16.1% of pT3 cases (73 of 455 pT3
patients) and 72.1% of pT4 cases (44 of 61 pT4 patients).
Conclusions: Our findings suggest that patients with a low or intermediate risk
PCa undergoing RARP from experienced surgeons exhibit an excellent surgical
margin status. In patients with a high-risk PCa or a ≥ pT3 pathologic stage, the
surgical margin status can be surely considered as acceptable.
60
P096: ROBOTIC RADICAL AND PARTIAL NEPHRECTOMY Nick
Pardalidis, Nick Andriopoulos, Aggelos Karamanis, Eleni Kosmaoglou Athens
Medical Centre, Athens, Greece
Objectives: We present our experience using the da Vinci system in renal tumors,
performing radical as well as partial nephrectonies.
Materials & Methods: Since 2006, 20 patients successfully underwent radical
nephrectomy for renal tumors, using transperitoneal approach. Our only
limitation was the size of the tumor (less than 4cm). We have also performed 8
partial nephrectomies at the same period, for solitary small renal tumors ’4cm.
Results: The mean operative time(console time) for radical nephrectomy was
165 min, blood loss 275 ml, mean tumor size was t.8 cm and mean hospital stay
was 2.8 days. Renal vessels were ligated either with haemolock clips or steplers.
No intra operative complications were encountered. For partial nephrectomy
procedures hilar clamping was used with a mean warm ischemia of 30 min.
The mean operative time was 168 min, mean blood loss was 280 ml and mean
hospital stay of 3.2 days
Conclusions: da Vinci radical as well as partial nephrectomy is a safe and effective
method for the management of renal cancer.
P097: RETROSPECTIVE STUDY ON ANATOMIC VARIATIONS OF
RENAL VESSELS BASED ON LAPAROSCOPIC-ROBOTIC SURGERY
EXPERIENCE Chady Waked, MD, Ibrahim-Michel Karam, MD, cyril
Perrenot, MD, Manuella Perez, MD, Pascal Eschwege, MDPhD, Michel
Claudon, MDPhd, Jacques Hubert, MDPhD Department of Urology, Brabois
Hospital, Nancy, France
Purpose: Evaluate the impact of the three-dimensional imaging on the dissection
of renal vessels and demonstrate the capacity of laparoscopic-robotics’ approach
on identifying and preserving these vessels mainly in the case of atypical vascular
variations and difficult and complex tumour localisation.
Methods & Equipment: The study was conducted on 100 cases of renal transplant
with living donor and 60 partial nephrectomies. A multislice CT scan
with 3D reconstruction based on MPVR technique with axial and oblique
reconstructions on the vessels level was performed on each patient. The
laparoscopic surgery was performed with a three arms Da Vinci Robot. We
compared imaging results with anatomic reality observed in intraoperative and
evaluated the role of 3D imaging on making the dissection of hilum and renal
tumours easier.
Results: We found many variations in the renal venous system: multiple veins on
the right side, on the left side we found some retro-aortic veins and circum-
aortic venous rings. The arterial vascularisation results from a single artery
in 75% of cases, two arteries in 20% and three arteries in 5% of cases. The
modality of division of the renal arteries is inconstant, but the bifurcation in
an anterior branch and a posterior branch are relatively constant. Our method,
based on 3D imaging and laparoscopic-robotic approach, reduced to null the
level of conversion and intraoperative bleeding.
Discussion: The multiphasic acquisition, with multi slice CT scan 3D
reconstruction permitted the establishment of an intraoperative cartography of
the vessels number and situation resulting in an easier dissection in the reduced
operative field. The 3D CTscan images and 3D robotic coupling leads operator
to conduct a selective dissection of renal vessels and overcome difficulties
represented by the atypical anatomic configuration. Furthermore, during partial
nephrectomy, the three-dimensional scanographic imaging allows the surgeon to
have a pre-operative clear vision as for the tumour localisation, its deepness and
vascularisation. This imaging, associated with three-dimensional and robotic
arms articulation, enables a better dissection of the tumour and renal hilum, and
helps the surgeon to control an eventual selective tumour artery.
Conclusion: This study demonstrated that 3D imaging provides high quality
images that make intraoperative anatomic analyzes more accessible to those
non-specialized in imaging mainly urologists. The interest of the excellent
correlation between three-dimensional representation and the intraoperative
vision is to give to the operator the capacity to anticipate difficulties and
overcome them.
Key Words: multislice CT scan, three-dimensional reconstruction, Da Vinci
Robot, robotic simulation, renal veins, renal arteries, partial nephrectomy.
6 TH ANNUAL MIRA CONGRESS May 11-13, 2011
MIRA
MIRA Membership Services
11300 W. Olympic Blvd #600
Los Angeles, CA 90064
Phone: 310.424.3353, ext. 134
Fax: 310.437.0585
Email: membership@mirasurgery.org
MINIM ALLY INVASIVE ROBOTIC ASSOCIATION WebSite: www.mirasurgery.org

APPLICATION FOR MEMBERSHIP

APPLICATION DATE: PLEASE TYPE OR PRINT CLEARLY

Please accept my application for the following membership category (check one):
ACTIVE MEMBER – an active surgeon in General Surgery, Colon & Rectal Surgery, Urology, Gynecology, Thoracic Surgery, Head & Neck or
Podiatric, and other surgical specialties who performs robotic interventions or actively involved in research or development.
(Membership Dues: $150 USD annually)
CANDIDATE MEMBER – a resident/fellow or graduate surgeon actively enrolled in a dedicated training program in which robotic interventions
form a part of the core curriculum. (No dues during residency/fellowship). Candidate status is maintained for up to three (3) years to allow for
these members to become integrated in minimally invasive robotic intervention.
Year Residency Completed: Year Fellowship Completed:
Upon completion of residency/fellowship or when board certified, annual dues of $150 USD will be paid for three (3) years following
residency/fellowship. At the end of 3 years, member will be upgraded to Active Member status.
ASSOCIATE MEMBER – a physician, nurse, engineer and other healthcare professional actively involved in robotic surgery.
(Membership Dues: $100 USD annually)

APPLICANT’S FULL NAME

Last/Family Name First/Given Name Middle Name or Initial

MD DO PhD RN LPN PA Other Degrees:

Date of Birth (month/day/year): Country of Birth:

PROFESSIONAL ADDRESS

Association or Institution

Department

Street Address

City State/Province Zip/Postal Code

Telephone Number Fax Number E-Mail Address

MEDICAL EDUCATION

Medical School Institution Dates Attended Degree/Date

Residency Institution Dates Attended Degree/Date

Fellowship Institution Dates Attended Title/Department

HOSPITAL APPOINTMENTS (List up to 3 most recent principle appointments only)

Name/Department/Location Year of Appointments Staff Position/Title

Name/Department/Location Year of Appointments Staff Position/Title

Name/Department/Location Year of Appointments Staff Position/Title

ACADEMIC APPOINTMENTS (Past and current)

University Dates Title

University Dates Title

LICENSURE/SPECIALTY

License State/Province/Country Date Issued License Number

Board Name/Specialty Date of Certification

SURGICAL SOCIETY MEMBERSHIPS

Name Date of Membership Office or Position Held

Name Date of Membership Office or Position Held

Name Date of Membership Office or Position Held

For the following three categories, list only information related to robotics:

Research

Presentations

Publications

REFERENCE

Name (Please print clearly) City/State Phone or E-mail Address

Please Enclose $100 USD Application Fee:

A check (USD only) is enclosed with this application. Please make checks payable to MIRA.
I authorize you to charge my: VISA MasterCard American Express
CC Number: Expiration Date: Amount:
Cardholder Name: Signature:

Mail, fax, or email this form with payment to: MIRA Membership Department
11300 W. Olympic Blvd., Suite 600 • Los Angeles, CA 90064
PHONE: +1.310.424.3353 FAX: +1.310.437.0585 EMAIL: membership@mirasurgery.org
Or apply online at: www.mirasurgery.org/membership.php