Left atrial myxoma: extraction by robotic and vacuum assistance

We report a single case of left atrial giant myxoma excision using the da Vinci S surgical system in a 47-year-old woman. A vacuum extractor device was designed to avoid tumor fragmentation or embolization. The myxoma was entirely removed under aspiration through the extractor device, achieving all the surgical tenets of myxoma excision.     

Complex Bileaflet Mitral Valve Repair (Barlow's) Using the da Vinci Robotic Surgical System

Robotic mitral valve repair (RMVR) is less invasive and potentially more precise. However, RMVR lengthens both cardiopulmonary bypass and arrested heart times. In our initial experience, only posterior leaflet repair and/or annuloplasty were performed. With increasing experience, we have performed more complex bileaflet RMVR. A 50-year-old man presented with severe mitral regurgitation. Transesophageal echocardiography (TEE) demonstrated a complex bileaflet prolapse and preserved left ventricular function. Through a 4 cm working port and with the da Vinci Robotic Surgical System (Intuitive Surgical, Sunnyvale, CA) RMVR was performed. Details of the technique and patient's hospital course are described. The repair comprised closure of clefts between A3 and P3, quadrangular resection of P2, transfer of multiple chords from P2 to A2/A3 and a #38 Cosgrove-Edwards (Edwards Lifesciences, Irvine, CA) band annuloplasty. Nitinol U-Clips (Medtronic, Minneapolis, MN) were used to complete the annuloplasty. Postoperative TEE showed no mitral regurgitation. The patient was discharged on the third postoperative day. Cardiopulmonary bypass and arrested heart times were 3 hours and 29 minutes and 2 hours and 59 minutes, respectively. Complex bileaflet repair of mitral valve with Barlow's disease can be successfully performed with the da Vinci Robotic Surgical System. Long-term follow-up is needed to assess the durability of repair.     

On the trail of Leonardo

A night course taken almost 25 years ago sparked an interest in Leonardo da Vinci that has become a passion for a London, Ont., neurosurgeon. Dr. Rolando Del Maestro now boasts one of the largest collections of da Vinci artifacts in North America.     

Léonard de Vinci (1452–1519): andrologue avant la lettre

Leonardo da Vinci devoted 41 years of his lifetime to anatomy and anatomical drawing and opened new horizons in these two disciplines. He is therefore justly considered to be the father of modern anatomy. Considering the great number of his anatomical drawings dealing with the male urogenital tract and its function, Leonardo da Vinci can also be considered to be the father of andrology.     

Robotic totally endoscopic multivessel coronary artery bypass grafting: procedure development, challenges, results

Closed-chest totally endoscopic coronary artery bypass grafting (TECAB) is feasible using robotic technology. During the early phases, TECAB was restricted to single bypass grafts to the left anterior descending artery system. Because most patients referred for coronary artery bypass surgery have multivessel disease, development of endoscopic multiple bypass grafting is mandatory. Experimental work on multivessel TECAB was carried out in the early 2000s, and first clinical cases were already performed. With further technological development of operating robots, double, triple, and quadruple TECAB has become feasible both on the arrested heart and on the beating heart. To date, 161 cases of multivessel TECAB using the da Vinci telemanipulation systems are published in the literature. The main advances enabling multivessel TECAB were the availability of a robotic endostabilizer for beating heart procedures and increased surgeon skills using remote access heart-lung machine perfusion and endo-cardioplegia. Both internal mammary arteries can be harvested and both radial artery and vein graft can be used in multivessel TECAB. Y-grafting and sequential grafting are feasible. Multivessel endoscopic surgical revascularization can be combined with percutaneous coronary interventions in advanced hybrid coronary revascularization. Time requirements for multivessel TECAB are significant, and conversion rates to larger thoracic incisions are higher than those observed for single-vessel TECAB. Clinical short- and long-term outcomes, however, seem to meet the standards of open coronary bypass surgery through sternotomy. The main advantages of multivessel TECAB are a completely preserved sternum, use of double internal mammary artery even in risk groups, and a remarkably short recovery time.     

Mediastinal parathyroidectomy with the da Vinci robot

Mediastinal parathyroid glands are often located in a position which is inaccessible through a cervical approach. Because of the significant morbidity of open surgery, the need for minimal invasive approaches is high. More recently, robotic systems have been introduced to refine the dissection and optimize the view in the mediastinal region. We present two cases. The first case is a 34-year-old woman who was diagnosed with primary hyperparathyroidism. Because a bilateral neck dissection disclosed no parathyroid adenoma, we performed a parathyroid sestamibi scan and computed tomographic scan of neck and mediastinum to look for aberrant parathyroid glands. Both showed a parathyroid adenoma in the mediastinum on the left side. The second case is a 66-year-old man. A sestamibi scan showed a parathyroid adenoma of 3 cm in the superior mediastinum which was confirmed by and computed tomographic scan. In both cases, we performed a parathyroidectomy with the da Vinci robotic system through a left-sided approach. Three thoracoports were inserted around the mammary gland for the robot and a fourth auxiliary port was positioned in between. Single-lung ventilation was installed, and the mediastinum was entered by opening the parietal pleura along the left phrenic nerve. The upper margin for dissection was the left brachiocephalic vein that was followed until the right pleura. All the tissue in front of the pericardium was dissected en bloc. The sinking test of the nodule and a preoperative frozen section analysis confirmed the diagnosis of parathyroid adenoma, which was also proven by rapid parathyroid hormone analysis. The resection of a parathyroid adenoma from the aortopulmonary window represents an ideal case for robotic surgery.     

Computer assisted laparoscopic pneumovesical ureter reimplantation a.m. Cohen: initial experience in a pig model

To assess the feasibility of a new variant of laparoscopic Cohen cross-trigonal ureter reimplantation in vesico-ureteral reflux (VUR) using telesurgical equipment. VUR was induced in 8 female pigs by transurethral unroofing of the ureteric orifices. Three months later the reflux was verified by a cystography. A cross-trigonal ureter reimplantation a.m. Cohen was performed by laparoscopic access to the bladder using the da Vinci telesurgical system. The 12 mm camera port was placed below the umbilicus, two 8 mm working ports for the robotic system were placed lateral to the rectus muscles and an additional port for assistance between camera and right working port. The outcome was assessed 3 months later by a new cystography. The operative time for a single reimplantation varied from 45 to 90 minutes. In all pigs the reflux disappeared after the procedure, which was complicated by a postoperative port hernia in two animals. Laparoscopic transvesical ureter reimplantation using telesurgical equipment is a feasible method in the few cases this procedure is indicated. The advantage of the robotic equipment is the better access to submucosal tunneling of the ureter and the intravesical suturing of the anastomosis indicated by shorter operative time and success rates similar to the open procedure.     

Leonardo da Vinci on atherosclerosis and the function of the sinuses of Valsalva

Although well studied by a medical scholar like Kenneth D. Keele, Leonardo da Vinci’s elaborate study of the heart is not generally known. This article focuses on two of Leonardo’s achievements concerning atherosclerosis and the sinuses of Valsalva. The first is his post-mortem observation on the degeneration of the vascular system in an old man, an early case history.     

达芬奇机器人与腹腔镜手术治疗胰腺癌的近期疗效比较及对血清CRP、PCT及肿瘤标志物的影响

摘要 目的：探讨达芬奇机器人与腹腔镜手术治疗胰腺癌的近期疗效比较及对血清C-反应蛋白（CRP）、降钙素原（PCT）及肿瘤标志物的影响。方法：选择2019年1月至2020年1月在我院接受治疗的61例胰腺癌患者,根据手术方法分为机器人组（n=26）和腹腔镜组（n=35）。腹腔镜组给予腹腔镜手术治疗,机器人组给予达芬奇机器人辅助治疗。比较两组围术期情况、CRP 、PCT、糖类抗原19-9（CA19-9）、糖类抗原125（CA125）、术后恢复情况及并发症发生情况。结果：机器人组禁食时间及排气时间显著低于腹腔镜组,差异显著（P<0.05）;治疗前,两组血清CA19-9、CA125水平无明显差异;治疗后,两组血清CA19-9、CA125水平治疗后较治疗前均显著下降差异显著（P<0.05）;两组治疗后血清CA19-9、CA125水平比较无显著差异（P>0.05）;治疗前,两组CRP、PCT水平无明显差异;治疗后,两组CRP、PCT明显升高,且机器人组低于腹腔镜组差异显著（P<0.05）;机器人组和腹腔镜组术后下床活动时间、拔尿管时间、术后住院时间比较无显著差异;机器人组术后重症监护时间显著低于腹腔镜组,差异显著（P<0.05）;两组患者治疗期间并发症总发生率分别为4.44%、6.67%,无显著差异（P>0.05）。结论：达芬奇机器人辅助能够显著提高胰腺癌手术质量,且对血清CRP 、PCT的影响较小,且对肿瘤标志物的影响与腹腔镜手术较为接近,为患者提供机器人微创治疗是未来临床的必然发展趋势。     

The Oberlin procedure for restoration of elbow flexion with the da Vinci robot: four cases

Robotics allows up to 40× visual magnification and 10× magnification of the surgeon's movements, and eliminates physiologic tremors. These properties should allow the development of mini-invasive limb surgery, especially of the brachial plexus. The purpose of this work was to test the feasibility of the restoration of elbow flexion according to the technique of Oberlin using a da Vinci robot. The authors' series included four patients (average age, 31 years) presenting with elbow flexion paralysis. They were operated on 8 months after injury using a da Vinci S robot. In three patients, the open technique (technique 1) was used, and the mini-invasive approach (technique 2) was used for the last one. Strength of elbow flexion was measured. After 1-year follow-up, all of the patients had recovered elbow flexion. No sensory or motor deficit was found in the ulnar nerve territory. There was no difficulty with technique 1; technique 2, however, required a conversion to technique 1 because of difficulty visualizing the operative field. The results of the authors' series show the feasibility of the robot-assisted technique for the Oberlin procedure. The lack of sensory feedback was not an issue. The development of specific retractors and instruments should improve the mini-invasive technique. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, V.     

BOOK REVIEWS

Book reviewed in this article:
Guide to the Botanical Gardens of Britain. Michael Young
An Irish Florilegium 11. Wendy Walsh, with introduction and notes by Charles Nelson.
The Gardens of Provence and the French Riviera. Michael Racine, Ernest J.-P. Boursier-Mougenot and Franqoise Binet
Collins Photoguide to Wild Flowers of Britain and Northern Europe. Oleg Polunin
Leonardo da Vinci on Plants and Gardens. William A. Emboden     

Robotic-assisted cryosurgical treatment of atrioventricular node reentrant tachycardia

Atrioventricular nodal reentrant tachycardias typically arise from the existence of variable refractoriness in fast and slow conduction pathways within the triangle of Koch, which provide input to the atrioventricular node. Standard therapy includes medical management and catheter-based ablation procedures. Robotic-assisted, minimally invasive cryosurgical modification of the atrioventricular node can provide definitive therapy for patients who fail traditional therapy. A 65-year-old man presented with a several-year history of recurrent atrioventricular nodal reentrant tachycardia. Despite medical management and attempted percutaneous ablation, the patient remained symptomatic with weekly episodes. Access was via a 4-cm right anterolateral thoracotomy and peripheral perfusion. The da Vinci S robotic system was used to manipulate the cryoprobe (CryoMaze Probe; ATS Medical, Plymouth, MN USA). A series of spot freezes (tip 60°C) were made along the boundaries of the triangle of Koch until transient complete heart block was achieved and nodal rhythm was recovered. At follow-up 3 weeks postoperatively, the patient was asymptomatic in first-degree heart block. Robotic-assisted cryosurgical atrioventricular node ablation is an effective, minimally invasive treatment for patients with atrioventricular nodal reentrant tachycardia.     

Mechanics of blood flow

The historical development of the mechanics of blood flow can be traced from ancient times, to Leonardo da Vinci and Leonhard Euler and up to the present times with increasing biological knowledge and mathematical analysis. In the last two decades, quantitative and numerical methods have steadily given more complete and precise understanding. In the arterial system wave propagation computations based on nonlinear one-dimensional modeling have given the best representation of pulse wave propagation. In the veins, the theory of unsteady flow in collapsible tubes has recently been extensively developed. In the last decade, progress has been made in describing the blood flow at junctions, through stenoses, in bends and in capillary blood vessels. The rheological behavior of individual red blood cells has been explored. A working model consists of an elastic membrane filled with viscous fluid. This model forms a basis for understanding the viscous and viscoelastic behavior of blood.     

Electromyographic response is altered during robotic surgical training with augmented feedback

There is a growing prevalence of robotic systems for surgical laparoscopy. We previously developed quantitative measures to assess robotic surgical proficiency, and used augmented feedback to enhance training to reduce applied grip force and increase speed. However, there is also a need to understand the physiological demands of the surgeon during robotic surgery, and if training can reduce these demands. Therefore, the goal of this study was to use clinical biomechanical techniques via electromyography (EMG) to investigate the effects of real-time augmented visual feedback during short-term training on muscular activation and fatigue. Twenty novices were trained in three inanimate surgical tasks with the da Vinci Surgical System. Subjects were divided into five feedback groups (speed, relative phase, grip force, video, and control). Time- and frequency-domain EMG measures were obtained before and after training. Surgical training decreased muscle work as found from mean EMG and EMG envelopes. Grip force feedback further reduced average and total muscle work, while speed feedback increased average muscle work and decreased total muscle work. Training also increased the median frequency response as a result of increased speed and/or reduced fatigue during each task. More diverse motor units were recruited as revealed by increases in the frequency bandwidth post-training. We demonstrated that clinical biomechanics using EMG analysis can help to better understand the effects of training for robotic surgery. Real-time augmented feedback during training can further reduce physiological demands. Future studies will investigate other means of feedback such as biofeedback of EMG during robotic surgery training.     

Metal trabecular bone reconstruction system better improves clinical efficacy and biomechanical repair of osteonecrosis of the femoral head than free vascularized fibular graft: A case–control study

In this study, we aim to compare and analyze the biomechanical repair and clinical efficacy of osteonecrosis of the femoral head (ONFH) with the use of metal trabecular bone reconstruction system and free vascularized fibular graft. The study enrolled 66 adult patients from medical records of nontraumatic ARCO 2A–3B stage ONFH. A simple ONFH model without surgical treatment was established in 13 cases, 29 cases were treated with metal trabecular bone reconstruction system, and 24 cases were treated with free vascularized fibular graft. Computer-recognized and extracted femur outlines were imported, and three-dimensional reconstructions were performed. The stress concentration and stress peak value were analyzed, and the Harris score, visual analog scale pain score, and operation status of the above patients were compared. Finally, quality of life assessment was performed using SF-36 scale. Metal trabecular bone reconstruction system provided less operation time, blood loss, and the total length of postoperative hospital stay than free vascularized fibular graft. Metal trabecular bone reconstruction system promoted bone reconstruction, increased bone mineral density and Harris score. The total clinical effective rate of young patients (20–40 years) was higher than that of older patients (41–60 years). Metal trabecular bone reconstruction system provided higher physical component summary, mental component summary, and role/social component summary than free vascularized fibular graft. This study demonstrates that both metal trabecular bone reconstruction system and free vascularized fibular graft can prevent or delay the progression of ONFH, while metal trabecular bone reconstruction system is a better choice because of better short-term clinical efficacy.     

A laminar cortical model of stereopsis and 3D surface perception: closure and da Vinci stereopsis

A laminar cortical model of stereopsis and 3D surface perception is developed and simulated. The model describes how monocular and binocular oriented filtering interact with later stages of 3D boundary formation and surface filling-in in the LGN and cortical areas V1, V2, and V4. It proposes how interactions between layers 4, 3B, and 2/3 in V1 and V2 contribute to stereopsis, and how binocular and monocular information combine to form 3D boundary and surface representations. The model includes two main new developments: (1) It clarifies how surface-to-boundary feedback from V2 thin stripes to pale stripes helps to explain data about stereopsis. This feedback has previously been used to explain data about 3D figure-ground perception. (2) It proposes that the binocular false match problem is subsumed under the Gestalt grouping problem. In particular, the disparity filter, which helps to solve the correspondence problem by eliminating false matches, is realized using inhibitory interneurons as part of the perceptual grouping process by horizontal connections in layer 2/3 of cortical area V2. The enhanced model explains all the psychophysical data previously simulated by Grossberg and Howe (2003), such as contrast variations of dichoptic masking and the correspondence problem, the effect of interocular contrast differences on stereoacuity, Panum's limiting case, the Venetian blind illusion, stereopsis with polarity-reversed stereograms, and da Vinci stereopsis. It also explains psychophysical data about perceptual closure and variations of da Vinci stereopsis that previous models cannot yet explain.     

Partial lobectomy via a ligature fracture technique: a method for multiple hepatic biopsies in nonhuman primates.

A ligature fracture technique was used to obtain multiple large (2 to 4 g) liver biopsy samples in both African green and cynomolgus monkeys. The technique was performed 195 times in 84 animals using three different surgical approaches, with no associated illness or mortality. In a subset of 18 animals, a slight decline in hematocrit percentage was noted during 14 days postsurgery (44.6 to 39.4%), but total plasma protein remained unchanged (5.98 to 5.95 g/dl). Serum alanine aminotransferase concentrations rose to 178.11 U/l at day 1 postoperatively, from a baseline value of 93.61 U/l. This elevation was transient, however, and declined to 49.65 U/l by day 14. Our experience has shown that the partial lobectomy via the ligature fracture technique is a safe and effective means to obtain multiple large samples of liver in nonhuman primates.     

INDICATIONS FOR PULMONARY RESECTION IN INFANTS AND CHILDREN

Improvements in anesthetic and surgical techniques, and the availability of antibiotic drugs have made pulmonary resection a safe procedure for even newborn and very ill infants when it is necessary for treatment of bronchiectasis, abscess of the lung, tumors, and congenital cysts, both infected and noninfected.In a series of 34 infants and children upon whom lobectomy or pneumonectomy was done, all were cured of the disease which dictated the operation. There were no deaths.     

腹腔镜肝癌切除术与开放式肝癌切除术的疗效比较研究

目的：探讨腹腔镜肝癌切除手术治疗原发性肝癌的可行性及安全性。方法：选取2008年6月至2011年1月在我院行腹腔镜肝癌切除术的30例患者作为研究对象,另外选择同期在我院行开放式肝癌切除术的30例患者作为对照。结果：30例均在腹腔镜下成功地完成手术,其中22例行腹腔镜局部切除术,8例行肝左外叶切除术。手术时间103—142min,出血量60-480mL,术后均未发生严重并发症,术后平均住院8．6d。术后随访18～36个月,局部复发或种植性转移率与对照组无显著差异。结论：腹腔镜肝癌切除术是安全可行治疗原发性肝癌的手术方式.