Transcript Diapositiva 1

ENDOSCOPIC SURGERY DISADVANTAGES
 UNNATURAL OPERATIVE FEEL
2-D VISION, HANDS AND INSTRUMENTS
MISALIGNED
 LIMITED DEXTERITY INSIDE PATIENTS
HANDS/WRIST OUTSIDE PATIENT
FIXED INSTRUMENTS TIPS INSIDE PATIENT
LONG INSTRUMENTS, INVERTED MOVEMENT
ONLY 4 DOF + GRIP
COMPUTER-ENHANCED SURGERY
TELESURGICAL PERFORMANCE ENHANCEMENT OF
ENDOSCOPIC SURGICAL TECHNIQUE THROUGH:
 INCREASED DEXTERITY AND PRECISION (6 DOF + GRIP)
 IMPROVED INTRA-CAVITARY RANGE OF MOTION
 VISUAL IMMERSION
 INTUITIVE MOTION (ANTHROPOMORPHIC CONCEPT)
 SCALING
 FILTERING
BASIC ORGANIZATIONAL CRITERIA
 STANDARDIZATION OF THE SURGICAL PROCEDURES
 INSTALLATION OF ROBOTIC SYSTEM AND PLANING THE
DISPOSITION OF THE OPERATING ROOM
 TRAINING OF SURGICAL TEAM
 ORGANIZATION OF THE WARD
 QUALITY CONTROL
STANDARDIZATION OF THE SURGICAL
PROCEDURES
IT IS NECESSARY TO PERFORM IN A SAFE
AND STRAIGHTFORWARD MANNER AN
EXTREMELY ADVANCED AND INNOVATIVE
MODALITY LIKE ROBOTIC SURGERY,
WHERE THE DETAILS TO ATTEND TO ARE A GREAT MANY.
TRAINING OF THE SURGICAL TEAM
 SCRUB NURSES
 TECHNICIANS
 SURGEONS
 ANESTHESIOLOGIST
TRAINING OF THE SURGICAL TEAM
ROOM PERSONNEL
(SCRUB NURSES, TECHNICIANS)
IT ALLOW THE CREATION OF A TEAM ABLE TO ACTIVATE AND
MAINTAIN THE ENTIRE OPERATIVE SYSTEM, TAKE CHARGE AND
HANDLING ALL MATERIALS AND INSTRUMENTS
APPROXIMATELY 15 DAYS ARE NECESSARY TO COMPLETE
ADEQUATE TRAINING OF PERSONNEL
GIULIANOTTI, OSP. ITAL. CHIR., 2001
TRAINING OF THE SURGICAL TEAM
ROOM PERSONNEL
 SETUP OF ROBOTIC SYSTEM
• Connection of the console to the robotic cart electric cables
and optic fibers
• System switch-on
• Self-test
• Draping of the robotic arms with insertion of electronic
microcircuit plates
• Fixing of mechanical supports for trocars on the robotic arms
 SETUP OF OPTIC SYSTEM ON THE CONSOLE
• Frontal or inclined position of the scope (0° - 30°)
• White balancing
• Setting of the 2-D or 3-D vision
• Vision centering for the monitor of the console
TRAINING OF THE SURGICAL TEAM
ASSISTANCE ON THE SURGICAL FIELD
INITIAL PHASE OF THE PROCEDURE
• Patient positioning
• Induction of pneumoperitoneum
• Placement of trocars
• Initial phase of surgical intervention (conventional VL)
• Robot cart positioning
• Introduction/extraction of the robotic surgical instruments
TRAINING OF THE SURGICAL TEAM
ASSISTANCE ON THE SURGICAL FIELD
SURGICAL PROCEDURE
 Placement of trocars
 Divarication and exposure of operative field
 Introduction of materials in operative field (stitches, needles, gauzes,
prostheses, endobags)
 Use of accessory instruments (clips, staplers, loops)
TRAINING OF THE SURGICAL TEAM
ASSISTANCE ON THE SURGICAL FIELD
FINAL PHASE OF THE SURGICAL PROCEDURE
• Extraction of operative specimens
• Exploration of operative field
• Introduction of drain tube
• Extraction of the trocars
• Desufflaction
• Removal of robotic station from patient
• First assistance in case of immediate conversion
QUALITY CONTROL
 EVALUATION MUST BE CRITICAL AND AIMED AT
INCREASING EFFICENCY, OPTIMIZING AVAILABLE
RESOURCES AND POSSIBLY LOWERING COSTS
 THE MOST SIGNIFICANT INDICATORS ARE:
- OPERATIVE TIME
- RATE OF CONVERSION
- MORBIDITY
- LENGTH OF HOSPITAL STAY
ROBOTIC SURGERY CENTER
 CLINICAL PRACTICE
 DIDACTIC ACTIVITY
 RESEARCH
LEARNING CURVE
SURGEON’S FAMILIARITIATION WITH FOLLOWING ASPECTS:
 BINOCULAR AND THREE-DIMENSIONAL VISION
 RESTRICTED OPERATIVE FIELD
 THE HANDLING OF JOYSTICKS
 ROBOTIC SURCICAL INSTRUMENTS
 MOVEMENTS OF ROBOTIC ARMS AND OF SURCICAL INSTRUMENTS
(CONPUTERED TREMOR REDUCTION, WRISTED INSTRUMENTS)
 ABSENCE OF TACTILE FEEDBACK
LEARNING CURVE
1. THEORETICAL PHASE
2. TRAINING AT THE CONSOLE (MECHANICAL OR ANIMALS MODELS)
3. KNOWLEDGE OF THE TECHNICAL ASPECTS OF THE ROBOTIC
SYSTEM, OF PROCEDURES FOR INSTALLING THE ROBOT ON
OPERATING FIELD, OF HANDLING OF SURGICAL INSTRUMENTS
4.CLINICAL APPLICATION (VL COLECISTECTOMY WITH TUTORING)
LEARNING CURVE IN ROBOTIC COLECISTECTOMY
T Student p = 0.002
MEDIAN
OPERATIVE
TIME:
RANGE
FIRTS 20
PATIENTS
38
PATIENTS
103.5 min
75.2 min
(50 – 210)
(30 – 120)
”20 PROCEDURES ARE NECESSARY TO COMPLETE THE LEARNING CURVE
FOR THIS PROCEDURE”
GIULIANOTTI, 2001
CRITERIA FOR EVALUATING ROBOTIC
LEARNING CURVE
MAIN PROBLEMS
 STANDARDISATION OF PATIENTS
 LACK OF METHODS TO OBJECTIVELY ASSESS PERFORMANCE
 THE MAJORITY OF STUDIES HAVE FOCUSED UPON DRY LAB EXPERIMENTS
HANCE J ET AL: J MEDICAL ROBOTICS AND COMPUTER ASSISTED SURGERY, 2005
CRITERIA FOR EVALUATING ROBOTIC
LEARNING CURVE
MAIN QUESTIONS
 “ DOES THE ROBOTIC LEARNING CURVE PLATEAU?”
AND
 “DOES PREVIOUS LAPAROSCOPIC EXPERIENCE LEAD TO
FASTER ACQUISITION OF TELEROBOTIC SKILLS?”
HANCE J ET AL: J MEDICAL ROBOTICS AND COMPUTER ASSISTED SURGERY, 2005
“QUALITATIVE AND QUANTITATIVE ANALYSIS OF THE
LEARNING CURVE OF A SIMULATED SURGICAL TASK ON THE
DA VINCI SYSTEM”
HERNANDEZ ET AL: SURG ENDOSC, 2004
METHODS
 13 SURGEONS COMPLETED FIVE SYNTHETIC SMALL BOWEL
ANASTOMOSES USING THE DA VINCI SYSTEM
 OBJECTIVE STRUCTURED ASSESMENT OF TECHNICAL SKILLS
(OSATS) ALLOWED QUALITATIVE ANALYSIS
 THE API (APPLICATION PROGRAMMING INTERFACE) SOFTWARE
USED TO RETRIEVE REAL-TIME ROBOTIC SIGNAL DATA OF
TIME, PATH LENGTH AND NUMBER OF MOVEMENTS (P VALUE
< 0.05 WAS CONSIDERED SIGNIFICANT)
“QUALITATIVE AND QUANTITATIVE ANALYSIS OF THE
LEARNING CURVE OF A SIMULATED SURGICAL TASK ON THE
DA VINCI SYSTEM”
HERNANDEZ ET AL: SURG ENDOSC, 2004
RESULTS
FIRST ATTEMP
OSATS GLOBAL SCORE POINTS
TIME (SEC.)
TOTAL NUMBER OF MOVEMENTS
TOTAL PATH LENGTH (CM)
18.6
3507
2411
21,630
FIFTH ATTEMP
p
26
2287
1387
13,941
0.02
0.008
0.01
0.01
“ROBOTIC SURGERY: IDENTIFYING THE LEARNING CURVE
THROUGH OBJECTIVE MEASUREMENT OF SKILL”
CHANG L ET AL: SURG ENDOSC, 2003
METHODS
 8 SURGEONS PERFORMED INTACORPOREAL KNOT TYING TASKS BEFORE AND
AFTER 3 WEEK SURGICAL ROBOTIC TRAINING
 THESE PERFORMANCE WERE COMPARED TO THEIR LAPAROSCOPIC
KNOTS AND ANALYZED TO DETERMINE AND DEFINE SKILL IMPROVEMENT
“ROBOTIC SURGERY: IDENTIFYING THE LEARNING CURVE THROUGH
OBJECTIVE MEASUREMENT OF SKILL”
CHANG L ET AL: SURG ENDOSC, 2003
RESULTS
TIME (SEC.)
LAPAROSCOPY
ROBOTIC SURGERY
140 (M.C.: 77)
390 (M.C.: 40)
AFTER 4-6 HOURS OF ROBOTIC TRAINIG
139 (M.C.: 71)
 “LEARNING CURVE MAY PLATEAU SOONER FOR ROBOTIC
MANIPULATIONS WHEN COMPARED TO MANUAL LAPAROSCOPY”
 “PREVIOUS EXPOSURE TO LAPAROSCOPY ENABLES A SURGEON TO
INCORPORATE ROBOTICS MORE RAPIDLY THAN A SURGEON WITH
NON PREVIOUS KNOWLEDGE OF MINIMAL INVASIVE SURGERY”
 “HOWEVER IT IS DIFFICULT TO ESTABLISH GUIDELINES FOR
CLINICAL TRAINING SOLELY FROM THIS DRY-LAB DATA”
HANCE J ET AL: J MEDICAL ROBOTICS AND COMPUTER ASSISTED SURGERY, 2005
RISULTATI
PROCEDURE: 43
DEGENZA MEDIA: 48.6 h
MORTALITA’:
MORBILITA’:
0
3
- OCCLUSIONE INTESTINALE: 1
- EMORRAGIA SITO TROCAR ACCESSORIO: 2
CONCLUSIONS
 IT IS NECESSARY TO STANDARDIZE PROCEDURES AND ESTABLISH
OPERATIVE SCHEMES AND TRAINING PROTOCOLS FOR THIS THECNOLOGY
 ADEQUATE TRAINING WILL ALLOW THE CREATION OF SURGICAL TEAM
(SURGEONS, ANESTHESIOLOGISTS, OPERATING ROOM PERSONNEL) ABLE
TO ACTIVATE AND MANTEIN THE ENTIRE OPERATIVE SYSTEM AND TO
APPLIE THE ROBOTIC THECHNIQUE IN MANY SUIRGICAL PROCEDURES
 TRAINING MUST BE DEDICATED TO SURGEONS WITH PREVIOUS
KNOWLEDGE OF CONVENTIONAL AND MINIMAL INVASIVE SURGERY
FUTURE TRAINING
 VIRTUAL REALITY SIMULATOR
- www.simsurgery.com (Norway)
- Two Handed Universal Master Console (THUMP)
 TELEMENTORING
 ENHANCEMENT OF SURGEON’S VIEW
- Simulation and Transfer Architecture for Robotic Surgery (STARS)
FUTURE TRAINING
 HIGH TECHNOLOGY FORMATION
MEDICAL LEGAL IMPLICATIONS