These basic courses are performed on training models in five levels of increasing complexity. This paper reviews the current state of the art in robotically asisted microsurgical training.
Developed in the s, microsurgery is a surgical technique using optical magnification that allows the microsurgeon to perform delicate movements which are difficult or impossible using the naked eye. Over the last few years, microsurgery has seen two major technical advances: The latter, telemicrosurgery or robotically assisted microsurgery can be defined as the technique of microsurgery that uses robotic telemanipulators to scale down surgical gestures or movements.
The da Vinci robot Intuitive Surgical Inc. RAMSES not only aims to promote microsurgery with robotic manipulators, but also aims to develop a new concept: It combines the properties of microsurgery, endoscopic surgery, and telesurgery.
This would not only allow magnification of the view of the operating field, but also enable microsurgeon to scale down the gestures or movements of the operator's hands, while taking a minimally invasive approach. The purpose of this paper is to describe the models used for training, evaluation methods, and the organization and proceedings of basic and advanced telemicrosurgery training.
The only surgical telemanipulator currently available on the market is the da Vinci robot Intuitive Surgical Inc. It consists of three components: The mobile cart contains four articulated robotic arms, three of which carry surgical instruments and a fourth arm that manipulates the digital stereoscopic camera to visualize the surgical field. Each of these arms has multiple joints providing three-dimensional movement of the surgical instruments and optics. The tools available vary: The fourth arm, which controls the optics, has a stereoscopic, high definition, endoscopic camera.
The stereoscopic camera lens comprises a video imaging column similar to that used in conventional laparoscopy or arthroscopy and two light sources and dual stereoscopic cameras for three-dimensional vision with progressive magnification up to 12 to 15 times. The surgeons' console is equipped with an optical viewing system, two telemanipulation handles, and five pedals. The optical viewing system, called the stereo viewer, offers a three-dimensional view of the operating field and displays text messages and icons that reflect the status of the system in real time.
The two telemanipulation handles allow remote manipulation of the four articulated robotic arms. In its latest version, the da Vinci SI, the robot is equipped with 2 surgeon consoles to allow for the simultaneous use with two operators: In this mode, the 3 robotic arms can be utilized at the same time by the two operators.
The robot da Vinci SI contains three parts from right to left: Five properties of the da Vinci robot are essential in telemicrosurgery. The optical magnification of the operating field is obtained by the optical and digital magnification of the stereoscopic camera. The suppression of physiological tremor improves the quality of surgical movements. The scaling down of surgical movements improves accuracy by reducing the surgeon's movements by a factor of 3 position "fine" or 5 position "extra-fine".
The ergonomic design of the surgeons' console is very useful in microsurgery because it improves the comfort of the surgical movements by simplifying the motion. The possibility of minimally invasive surgery allows the microsurgeon to work in unique operative fields with minimal cutaneous incisions. Robotic telemanipulators have often been criticized for not having tactile feedback.
In reality, it has been clearly demonstrated that force or tactile feedback is not absolutely necessary in microsurgery: Successful microsurgery with suture-assisted microsurgical robots has already been reported [ 5 ]. In addition, a new robotic platform, the Amadeus telemanipulator Titan , that will be available soon, will be equipped with tactile feedback. It is not difficult to imagine that, in the future, there will be a robot able to replicate microsurgical maneuvers with tactile feedback force, possibly enabling endoscopic supermicrosurgery [ 1 ].
Among the models currently available in conventional microsurgery, there are nonliving non-biological models latex, silicone, Gore-Tex, PracticeRat , nonliving biological models artery of the chicken wing, pig's feet, placenta and living models mouse, rat, rabbit [ 6 , 7 ]. The ideal model would meet the following specifications: No model perfectly fulfills all these specifications and full education in telemicrosurgery must have several levels of increasing complexity, the ability to address technical challenges, and applicability to varying microsurgical procedures.
The first level is to become familiar with the robot and master the basic skills of telemicrosurgery. This can be done either by means of an analog simulator such as plastic rings Fig. Several simulators are available on the market: Mimic, Ross [ 9 ], dV-Trainer [ 10 ], and da Vinci skills simulator [ 11 ]. The virtual simulators assess students' performances in terms of time to complete the exercise, gesture accuracy, missed targets, instrument collision, drops, etc. This is one reason why virtual simulators allow for highly efficient self-teaching Fig.
Installation of a robot da Vinci SI for level 1 training. Plastic rings must be manipulated and moved from one display stand to the other. No measure of performance is possible with this model, except the time of realization of the task.
Robotics in Microsurgery to Date | MMI Microinstruments — Medical Microinstruments (MMI)
Installation of the da Vinci skills simulator for level 1 training. Several tasks of increasing difficulty can be developed, including vascular sutures. Precise measures of performance allow for self-education. The second level is to use telemicrosurgical sutures on inexpensive models that pose no ethical dilemma in terms of animal testing.
We use calibrated earthworms Lombricus rubellus with an average length of 60 mm and a mean outer diameter of 3 mm Fig.
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Each end of the worm is then cut with a scalpel followed by gentle finger pressure applied from one end to the other in order to completely eviscerate the worm. One obtains a hollow tube, the lumen, which replicates the lumen of a vessel of an average internal diameter of 2 mm. A frank cut in the middle of the model produces two segments of equal length ready to be anastomosed [ 12 ]. After anastomosis, the permeability and tightness of the model can be tested by injecting saline solution through one end [ 13 ]. It is also possible to use the femoral vessels of chicken thighs Fig.
However, this model is less attractive than the worm because of its higher cost and the greater difficulty of its preparation. Preparation of one worm for level 2 training. Preparation of a femoral artery of a chicken leg for level 2 training. The third level is to perform telemicrosurgical sutures on living models.
Telemicrosurgery: robot-assisted microsurgery
The rat model for instance, must be used in accordance with current legislation on animal experimentation. The telemicrosurgeon, as well as the microsurgeon, must learn to perfectly master the vascular sutures: Preparation of an artery of the tail of a rat for level 3 training.
Preparation of a rat sciatic nerve for level 3 training. The fourth level is to perform more complex telemicrosurgical maneuvers. A thawed fresh human cadaver is an ideal model on which to learn to manipulate nerve regrowth scaffolds Fig. Reimplantations on living animals can also be performed [ 18 ]. Preparation of a fresh human cadaver forearm for level 4 training. Preparation of a fresh human cadaver hand for level 4 training. The pedicle of the first dorsal interosseous space is isolated before raising a kite flap. The fifth and final level is reserved for endoscopic telemicrosurgery.
It consists of telemicrosurgical manuevers through minimally invasive incisions. Comments from a beginner in robotic colorectal surgery. Laparoscopic colorectal surgery is currently a well-established approach. The robotic approach is emerging. In this lecture, Dr.
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Symptoms are generalized to her four arms. In recent months, her symptoms worsened with the onset of swallowing disorders. Immunoglobulin treatment was poorly effective and was complicated by the appearance of jaundice. CT-scan showed a mediastinal thymic hyperplasia. Pathological findings demonstrated the presence of a lymphoid thymic hyperplasia.
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The advantage of this technique is the possibility to proceed with a radical thymectomy enlarged to the mediastinal fat exactly in the same way as for a median sternotomy, which is the standard technique. These instruments allow for an access to the lower cervical area without the use of a cervicotomy. Robot-assisted laparoscopic mesh excision of the rectum after rectopexy. This video demonstrates the excision of a mesh of rectopexy during a robot-assisted laparoscopic surgery.
This mesh has migrated through the anterior wall of the rectum. The first step of procedure shows dissection and mesh removal. The second step shows the suture of the anterior wall of the rectum. No stoma was required during the operation and afterwards. The objective of this video is to demonstrate the feasibility of a complex pelvic surgery using a robotic laparoscopic approach. Laparoscopic robotic-assisted partial nephrectomy. This video describes the procedure of partial nephrectomy performed with the DaVinci robot.
The renal pedicle is first isolated and temporarily controlled with vascular clamps. The partial nephrectomy is then performed in a bloodless field. Robot-assisted ultrasound-guided transgastric cystogastrostomy. We report the case of a year-old woman with a voluminous pseudocyst in the lesser sac after several episodes of acute pancreatitis of biliary origin managed by a robot-assisted transgastric cystogastrostomy.
The patient is lying supine, legs apart. Five ports are positioned. The intervention is begun with an anterior gastrotomy, which allows to introduce a balloon-tipped trocar transgastrically. A second gastrotomy is performed in the prepyloric region. It allows to introduce a second transgastric trocar. Finally, a third gastrotomy is performed at the level of the fundus to introduce a third transgastric balloon-tipped trocar. A transgastric ultrasonography is performed to visualize the pseudocyst, which has a heterogeneous content, with fibrotic debris.
The cyst is multilocular. The gastric wall is controlled by means of a Doppler ultrasound in order not to pass through the gastric varices, which had been identified on endoscopic ultrasound. A second cavity with some more heterogeneous content is subsequently opened.