Seminars in laparoscopic surgery最新文献

Esophagus resection is the adequate treatment for some benign esophageal diseases, especially caustic and peptic stenosis and end-stage motility dysfunction. However, the most frequent indications for esophageal resection are the high-grade dysplasia of Barrett esophagus and nonmetastasized esophageal cancer. Different procedures have been developed to perform esophageal resection given the 5-year survival rate among operated patients of only 18%. The disadvantage of the conventional approach is the high morbidity rate, especially with pulmonary complications. Minimally invasive esophageal resections, which were first performed in 1991, may reduce this important morbidity and preserve the oncologic outcome. The first reports of morbidity and respiratory complications with this approach were discouraging and it seemed likely that the procedure would have to be abandoned. However, in the last 5 years, an important impetus for these techniques was given by Japanese groups and the group of Luketich in Pittsburgh. The outcomes of these new series are different than those of the beginning period, leading to an enormous expansion worldwide. Important factors for this change are the standardization of the operative technique, the experience of many surgeons with more advanced laparoscopic procedures, important improvements in instruments for dissection and division of tissues, a better anesthesia technique, and a better selection of patients for operation. Two minimally invasive techniques are being perfected: the three-stage operation by right thoracoscopy and laparoscopy, and the transhiatal laparoscopic approach. It seems that the first approach may be applied successfully for any tumor in the esophagus, whereas the transhiatal seems ideal for distal esophageal and esophagogastric junction tumors. This review paper discusses all these aspects, with special attention for indications and operative technique.

Medical image processing leads to an improvement in patient care by guiding the surgical gesture. Three-dimensional models of patients that are generated from computed tomographic scans or magnetic resonance imaging allow improved surgical planning and surgical simulation that offers the opportunity for a surgeon to train the surgical gesture before performing it for real. These two preoperative steps can be used intra-operatively because of the development of augmented reality, which consists of superimposing the preoperative three-dimensional model of the patient onto the real intraoperative view. Augmented reality provides the surgeon with a view of the patient in transparency and can also guide the surgeon, thanks to the real-time tracking of surgical tools during the procedure. When adapted to robotic surgery, this tool tracking enables visual serving with the ability to automatically position and control surgical robotic arms in three dimensions. It is also now possible to filter physiologic movements such as breathing or the heart beat. In the future, by combining augmented reality and robotics, these image-guided robotic systems will enable automation of the surgical procedure, which will be the next revolution in surgery.

The history of robotics can be traced back to the automata of ancient Greece, but it has only been within the last 50 years that machines have been made to mimic human actions in order to perform labor rather than to entertain and amuse. Furthermore, it has been only within the last 20 years that robotic technology has been applied to the practice of surgery. The goal of this technology has not been to replace the surgeon, but rather to enhance his or her performance with highly advanced tools. We present a brief history of some of the key points in the development of surgical robotics and discuss the advantages and disadvantages of the various US Food and Drug Administration-approved robotic surgical systems and surgical robots in general.

Beyond current laparoscopic surgery is the emergence of robotic surgery. The power of this type of surgery is converting both vision and hand motions into electronic signals (video and telemanipulation), which completes the transition of surgery from the Industrial Age to the Information Age. Other advances include replacing scrub and circulation nurses with robots, miniaturization, biosurgery, "intelligent" instruments, and energy-directed rather than mechanical surgical tools. These modalities will supplement-but not totally replace-current forms of surgery such as open conventional, minimally invasive, endoluminal, and interventional.

The main advantages of robot-assisted orthopedic surgery over conventional orthopedic techniques are improved accuracy and precision in the preparation of bone surfaces, more reliable and reproducible outcomes, and greater spatial accuracy. Orthopedic surgery is ideally suited for the application of robotic systems. The ability to isolate and rigidly fix bones in known positions allows robotic devices to be securely fixed to the bone. As such, the bone is treated as a fixed object, simplifying the computer control of the robotic system. Commercially available robotic systems can be categorized as either passive or active devices, or can be categorized as positioning or milling/cutting devices. Computer assisted orthopedic surgery is a related area of technological development in orthopedics; however, robot-assisted orthopedic surgery can achieve levels of accuracy, precision, and safety not capable with computer assisted orthopedic surgery. Applications of robot-assisted orthopedic surgery currently under investigation include total hip and knee replacement, tunnel placement for reconstruction of knee ligaments, and trauma and spinal procedures. Several short-term studies demonstrate the feasibility of robotic applications in orthopedics, however, there are no published long-term data defining the efficacy of robot-assisted orthopedic surgery. Issues of cost, training, and safety must be addressed before robot-assisted orthopedic surgery becomes widely available. Robot-assisted orthopedic surgery is still very much in its infancy but it has the potential to transform the way orthopedic procedures are done in the future.

Surgical robotics, the result of the combined efforts of engineers, computer scientists, entrepreneurs, and surgeons, has enabled the surgeon to execute precise technical maneuvers while seated at a remote console. The capability to perform sophisticated surgical operations by means of a robot is today's reality. The combination of laparoscopy and robotics has the potential to enhance operative performance and the outcomes of laparoscopy, and expand the clinical application of laparoscopy while reducing patient morbidity. In this article, we review initial pioneering and laboratory research, early clinical investigations, and current clinical applications of robotics in urologic surgery.

A potential application of robotic surgical systems is to act as the hands and eyes of a surgeon operating from a considerable distance, enabling the surgeon to offer a variety of surgical services through gaining true telepresence by the interface of the telecommunication link and a surgical robotic system. The limited use of robot-assisted remote telepresence surgery to date has demonstrated not only that this is technologically feasible and safe but also that the patients are willing to accept its limitations when it is used in an environment where significant value from its use is realized. This chapter will discuss some of the lessons learned, the potential future applications, and the necessary next steps for its safe and widespread adoption.

Technological advances in the modern operating room have pushed neurosurgeons to the limits of their dexterity and stamina. Motion scalers and tremor filters on robots permit unprecedented precision of tool manipulation, upgrading the human hand, and closing the deftness deficit. The evolution of neurosurgical robots from stereotactic systems to hybrid systems capable of both stereotaxy and microsurgery is examined. The future of robot-assisted neurosurgery, including expanded tool sets and the prospect of semi-autonomous surgery, is discussed.

With the initiation of laparoscopic techniques in general surgery, we have seen a significant expansion of minimally invasive techniques in the last 16 years. More recently, robotic-assisted laparoscopy has moved into the general surgeon's armamentarium to address some of the shortcomings of laparoscopic surgery. AESOP (Computer Motion, Goleta, CA) addressed the issue of visualization as a robotic camera holder. With the introduction of the ZEUS robotic surgical system (Computer Motion), the ability to remotely operate laparoscopic instruments became a reality. US Food and Drug Administration approval in July 2000 of the da Vinci robotic surgical system (Intuitive Surgical, Sunnyvale, CA) further defined the ability of a robotic-assist device to address limitations in laparoscopy. This includes a significant improvement in instrument dexterity, dampening of natural hand tremors, three-dimensional visualization, ergonomics, and camera stability. As experience with robotic technology increased and its applications to advanced laparoscopic procedures have become more understood, more procedures have been performed with robotic assistance. Numerous studies have shown equivalent or improved patient outcomes when robotic-assist devices are used. Initially, robotic-assisted laparoscopic cholecystectomy was deemed safe, and now robotics has been shown to be safe in foregut procedures, including Nissen fundoplication, Heller myotomy, gastric banding procedures, and Roux-en-Y gastric bypass. These techniques have been extrapolated to solid-organ procedures (splenectomy, adrenalectomy, and pancreatic surgery) as well as robotic-assisted laparoscopic colectomy. In this chapter, we review the evolution of robotic technology and its applications in general surgical procedures.

The use of robotics is evolving in cardiac surgery. Robots allow minimally invasive techniques to be applied to ischemic heart and valve disease. Notably, this frees the patient from sternotomy, allowing a quick recovery while preserving the most critical aspects of the surgical procedure. The increasing use of stents for revascularization is significant. For best results to the patient, the graft of the left internal mammary artery (LIMA) to the left anterior descending artery (LAD) is a mainstay of symptom-free survival. Stenting and robotic LIMA-to-LAD grafting in a one-staged or two-staged approach may be an attractive combined specialty treatment. This would offer best practices to the patient, along with the best technologies available. In this chapter, the most common techniques in cardiac robotic surgery are outlined. Procedural steps are described, and their expanding indications for use discussed. Additionally, a focus on combining technologies for new treatments is considered.