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Conformity of tumour volumes and dose plans in prostate brachytherapy (BT) can be constrained by unwanted needle deflections, needle access restrictions and visualisation limitations. This work validates the feasibility of teleoperated robotic control of an active steerable needle using magnetic resonance (MR) for guidance. With this system, perturbations can be counteracted and critical structures can be circumvented to access currently inaccessible areas. The system comprises of (1) a novel steerable needle, (2) the minimally invasive robotics in an MR environment (MIRIAM) system, and (3) the daVinci Research Kit (dVRK). MR scans provide visual feedback to the operator controlling the dVRK. Needle steering is performed along curved trajectories to avoid the urethra towards targets (representing tumour tissue) in a prostate phantom with a targeting error of 1.2 ± 1.0 mm. This work shows the potential clinical applicability of active needle steering for prostate BT with a teleoperated robotic system in an MR environment.

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BACKGROUND: Transoral robotic surgery (TORS) for tongue base lesions located above the operative field is predominantly an upward procedure, which makes surgery difficult. METHODS: To illustrate our technique for this procedure, we report the case of an 82-year-old male with a p16-negative oropharyngeal carcinoma of the tongue base who underwent TORS. The field of view was turned upside down, and the operation switched the typical left- and right-arm functions. The daVinci Xi was docked, the 0° endoscope was rotated 180°, and the first arm was switched to the right hand and the third arm to the left hand. RESULTS: Although the lesion extended from the tongue base to the soft palate and mobile tongue, the planned resection line was followed. CONCLUSIONS: This technique improves operability by allowing downward manipulation and preventing the left and right arms from crossing. Further validation of the technique's effectiveness and safety is needed.

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Reports of mitral valve replacement after MitraClip removal have increased; however, surgical re-intervention is risky due to patients' frailty and comorbidities. We report a case of mitral valve repair after MitraClip failure using the daVinci surgical system for a 55-year-old man with many comorbidities and two previous cardiac surgeries. The daVinci surgical system allows detailed handling with high-resolution visualization and endowrist instruments that provide surgeons with clear three-dimensional images and stabilized handling. This procedure enables us to remove the MitraClip precisely while preserving the mitral valve leaflet.

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BACKGROUND: Cavernous hemangioma, as a rare tumor, is difficult to differentiate from retroperitoneal lymphoma and paraganglioma. They are more difficult to excise completely through open surgery and traditional laparoscopic surgery. The study aimed to evaluate the role of DaVinci surgical system in laparoscopic resection of parapelvic cavernous hemangioma. CASE PRESENTATION: A 46-year-old female, who diagnosed as parapelvic cavernous hemangioma accompanying with thrombosis and calcification, was performed laparoscopic resection using DaVinci surgical system under general anesthesia. The patient well recovered without recurrence or spread of the lesion after operation for 3 months as well as hydronephrosis was significantly relieved. CONCLUSION: Laparoscopic resection of parapelvic cavernous hemangioma under the help of DaVinci surgical system was feasible and safe.

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Robotic-assisted surgery is evolving, with improving clinical and cancer outcomes. The aim of this study was to present the clinical and cancer outcomes of patients undergoing robotic-assisted colorectal surgery (RAS-CR) at University Hospital Limerick (UHL) since its introduction to the 100th case, using the daVinci Xi dual-console surgical system. The RAS-CR programme at UHL commenced in June 2016 and the 100th case was performed in July 2019. All patient-related data were recorded prospectively during the perioperative period by the RAS-CR team. Statistical analysis was performed using SPSS, version 22. One hundred patients were operated on, comprising of 47 males and 53 females. The median age was 65 years (IQR 13.0; range 25-84) with 69% of cases performed for cancer [N = 39 rectal cancer, N = 30 colon cancer], 20% for benign disease and 11% for dysplasia. Median length of stay for cancer operations was 6.5 days for colon cancer cases (5.0 days when cases with complications were excluded) and 7.0 days for rectal cancer cases. Median operative time was 255 mins (IQR 130 min; all cases), median docking time was 33 mins (IQR 20 mins) and median intra-operative blood loss was 80 ml (IQR 70 ml). Thirty-one patients developed a post-operative complication (5% anastomotic leak; 13% SSI). In cancer cases, median nodal harvest was 14 nodes (IQR10) and an R0 resection was achieved in 98.6% (n = 68) of cancer cases. Three patients (4.3%) developed metastatic disease at a median interval of 16.5 months. Clinical and operative outcomes remained stable over time from case 1 to 100. Structured introduction of a RAS-CR programme with appropriate governance and continuous audit results in favourable clinical and cancer outcomes and provides an excellent training opportunity for surgical residents.

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STUDY OBJECTIVE: To examine whether a robotic surgical platform can complement the fine motor skills of the nondominant hand, compensating for the innate difference in dexterity between surgeon's hands, thereby conferring virtual ambidexterity. DESIGN: Crossover intervention study (Canadian Task Force classification II-1). SETTING: Centers for medical simulation in 2 tertiary care hospitals of Harvard Medical School. PARTICIPANTS: Three groups of subjects were included: (1) surgical novices (medical graduates with no robotic/laparoscopic experience); (2) surgeons in training (postgraduate year 3-4 residents and fellows with intermediate robotic and laparoscopic experience); and (3) advanced surgeons (attending surgeons with extensive robotic and laparoscopic experience). INTERVENTIONS: Each study group completed 3 dry laboratory exercises based on exercises included in the Fundamentals of Laparoscopic Surgery (FLS) curriculum. Each exercise was completed 4 times: using the dominant and nondominant hands, on a standard laparoscopic FLS box trainer, and in a robotic dry laboratory setup. Participants were randomized to the handedness and setting order in which they tackled the tasks. MEASUREMENTS AND MAIN RESULTS: Performance was primarily measured as time to completion, with adjustments based on errors. Means of performance for the dominant versus nondominant hand for each task were calculated and compared using repeated-measures analysis of variance. A total of 36 subjects were enrolled (12 per group). In the laparoscopic setting, the mean overall time to completion of all 3 tasks with the dominant hand differed significantly from that with the nondominant hand (439.4 seconds vs 568.4 seconds; p = .0008). The between-hand performance difference was nullified with the robotic system (374.4 seconds vs 399.7 seconds; p = .48). The evaluation of performance for each individual task also revealed a statistically significant disparate performance between hands for all 3 tasks when the laparoscopic approach was used (p = .003, .02, and .01, respectively); however, no between-hand difference was observed when the tasks were performed robotically. On analysis across the 3 surgeon experience groups, the performance advantage of robotic technology remained significant for the surgical novice and intermediate-level experience groups. CONCLUSION: Robot-assisted laparoscopy may eliminate the operative handedness observed in conventional laparoscopy, allowing for virtual ambidexterity. This ergonomic advantage is particularly evident in surgical trainees. Virtual ambidexterity may represent an additional aspect of surgical robotics that facilitates mastery of minimally invasive skills.

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Objective Reports are relatively few at home and abroad onrobot-assistedlaparoscopic ureteral reimplantation ( RAUR) .This study summarizes our experience with RAUR and assesses the feasibility and clinical effect of the strategy . Methods We retrospectively analyzed the clinical data about 5 cases of lower ureterostenosistreated by RAUR in our department from May 2015 to February 2017. Results Operations were successfully completed in all the cases , with an estimatedintraoperative blood loss of 40-100 mL but no blood transfusion , nor conversion to open surgery , nor intestinal or major vascular injury .The urethral catheter was re-moved at 5-7 days after surgery and there were no postoperative complications .The patients were followed up for over 6 months , during which all showed increased glomerular filtration rate ( 2-12 mL/min) of the involved kidney at 3 months and ultrasonography revealed no ureterostenosisorhydronephrosis . Conclusion Robot-assistedlaparoscopic ureteral reimplantation is a safe , effective and minimally invasive surgical option for distal ureteral obstruction .

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BACKGROUND/AIM: Robot-assisted surgery has become increasingly routine, replacing open and laparoscopic techniques in certain domains, with recent extension to head and neck surgery through trans-oral access. Some advantages of the robot-assisted surgery include the ability to access confined spaces, enhanced dexterity instrumentation with intuitive movement, motion scaling, tremor elimination and three-dimensional (3D) endoscopic viewing with true depth perception. The aim of this study was to investigate the technical feasibility of trans-oral robotic cleft surgery (TORCS) to access the posterior pharyngeal wall and palate for potential use in the cleft population. METHODS: All possible permutations of patient and robotic instrument configurations were used with the daVinci Si Surgical System® (Intuitive Surgical, USA) 0° and 30° 3D endoscopes and 8-mm training instruments to determine the optimal visualization and surgical access to the palate and posterior pharynx in a paediatric airway manikin, and to simulate posterior pharyngeal wall surgery. A full robot-assisted cadaveric Hynes pharyngoplasty was performed using 5-mm training instruments. Experiments were recorded with still and video photography. RESULTS: TORCS is technically feasible in the paediatric cleft population. We predict a short learning curve due to the intuitive instrumentation, easier dissection and the potential to limit secondary insult compared with traditional surgery, as well as improved ergonomics for the operating surgeon. CONCLUSIONS: The as-yet unreported use of robotic-assisted cleft palate surgery may considerably enhance a surgeon's ability to perform difficult procedures of the palate and posterior pharynx in selected patients with limited access as well as lay the foundation for potential novel techniques.

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