Virtual reality simulation for the optimization of endovascular procedures : current perspectives

Endovascular technologies are rapidly evolving, often - requiring coordination and cooperation between clinicians and technicians from diverse specialties. These multidisciplinary interactions lead to challenges that are reflected in the high rate of errors occurring during endovascular procedures. Endovascular virtual reality (VR) simulation has evolved from simple benchtop devices to full physic simulators with advanced haptics and dynamic imaging and physiological controls. The latest developments in this field include the use of fully immersive simulated hybrid angiosuites to train whole endovascular teams in crisis resource management and novel technologies that enable practitioners to build VR simulations based on patient-specific anatomy. As our understanding of the skills, both technical and nontechnical, required for optimal endovascular performance improves, the requisite tools for objective assessment of these skills are being developed and will further enable the use of VR simulation in the training and assessment of endovascular interventionalists and their entire teams. Simulation training that allows deliberate practice without danger to patients may be key to bridging the gap between new endovascular technology and improved patient outcomes

Abdominal decompression for abdominal compartment syndrome in critically ill patients: a retrospective study

Background. The abdominal compartment syndrome (ACS) refers to organ dysfunction that may occur as a result of increased intra-abdominal pressure (IAP). Successful management may require abdominal decompression and temporary abdominal closure (TAC). The aim of this study was to analyze the characteristics of patients requiring abdominal decompression, to describe the methods used for TAC, and to study the outcome of these patients. Methods. A series of critically ill patients who required abdominal decompression for ACS between January 2000 and March 2007 were reviewed retrospectively. Age, gender, severity of organ dysfunction before decompression and the cause of ACS as well as the type of abdominal closure system and length of ICU-stay were recorded. Definitive abdominal closure and in-hospital mortality were the main outcome parameters. Results. Eighteen patients with primary ACS and 6 with secondary ACS required decompressive laparotomy. Patients ages ranged from 18 to 89 years (mean 50.7). The median preoperative IAP was 26mmHg, and IAP decreased to 13mmHg after decompressive laparotomy. Organ function, as quantified by the SOFA scoring system, improved significantly after the intervention. Eight patients had immediate primary fascial closure after the decompressive procedure and 16 patients required TAC. The majority of the survivors underwent planned ventral hernia repair at a later stage. The mean length of stay in the ICU was 23 (+/- 16) days. Overall, fifteen patients survived (63%). Conclusions. Decompressive laparotomy was effective in reducing IAP and was associated with an improvement in organ function. In most of the patients, the abdomen could not be closed after decompression, and fascial repair was delayed

Total intracorporeal robot kidney autotransplantation : case report and description of surgical technique

Introduction and Objectives: Kidney autotransplantation can be performed in patients with complex renal or ureteral pathology not suitable for in situ reconstruction, such as renal vasculature anomalies, patients with proximal or long complex ureteral strictures, or complex oncological cases. Robot-assisted surgery allows for a high-quality vascular and ureteral anastomosis and faster patient recovery. Robot-assisted kidney autotransplantation (RAKAT) is performed in two phases: nephrectomy and pelvic transplantation. In-between, extraction of the kidney allows for vascular reconstruction or kidney modification on the bench and safe cold ischemia can be established. If no bench reconstruction is needed, total intracorporeal RAKAT (tiRAKAT) is feasible. One case report in Europe has been described; however, to our knowledge no surgical video is available. Methods: A 58 year-old woman suffered from right mid- and distal ureteral stenosis following pelvic radiotherapy 10 years prior for cervical cancer. A JJ stent was placed, but she suffered from recurrent urinary tract infections, and ultimately a nephrostomy was placed. Renogram demonstrated 43% relative right kidney function. As her bladder volume was low following radiotherapy, no Boari flap was possible and the patient refused life-long nephrostomy or nephrectomy. Therefore, tiRAKAT was performed using the DaVinci Xi system. Results: We describe our surgical technique including a video. Surgical time (skin-to-skin) was 5 h and 45 min. Warm ischemia time was 4 min, cold ischemia 55 min, and rewarming ischemia 15 min. The abdominal catheter and bladder catheter were removed on the first and second postoperative day, respectively. The JJ stent was removed after 4 weeks. The patient suffered from pulmonary embolism on the second postoperative day, for which therapeutic low molecular weight heparin was started. No further complications occurred during the first 90 postoperative days. After 7 months, overall kidney function remained stable, right kidney function dropped non-significantly from 27 to 25.2 mL/min (-6.7%) on renal scintigraphy. Conclusion: We demonstrated feasibility and, for the first time, a surgical video of tiRAKAT highlighting patient positioning, trocar placement, and intracorporeal cold ischemia technique

Robot-Assisted Kidney Transplantation

Robot-assisted kidney transplantation (RAKT) has recently been introduced to reduce the morbidity of open kidney transplantation (KT). Robot-assisted surgery has been able to overcome many of the limitations of classical laparoscopy, certainly in complex and technically demanding procedures, such as vascular and ureteral anastomosis. Since the first RAKT in 2010, this technique has been standardized and evaluated in highly experienced robot and KT centers around the world. In Europe, the European Association of Urology Robotic Urology Section (ERUS) created an RAKT working group in 2016 in order to prospectively follow the outcomes of RAKT. When performed by surgeons with both robotic and KT experience, RAKT has been proven to be safe and reproducible in selected cases and yield excellent graft function with a low complication rate. Multiple institutions have now adopted RAKT, and its use will likely increase in the near future. However, structured training and proctoring will be mandatory for those embarking on RAKT in order to help them negotiate the learning curve and avoid technical mistakes. This chapter will describe RAKT from living and deceased donors and its application in kidney autotransplantation (KAT)

Pediatric challenges in robot-assisted kidney transplantation

Kidney transplantation is universally recognized as the gold standard treatment in patients with End-stage Kidney Disease (ESKD, or according to the latest nomenclature, CKD stage 5). Robot-assisted kidney transplantation (RAKT) is gradually becoming preferred technique in adults, even if applied in very few centra, with potentially improved clinical outcomes compared with open kidney transplantation. To date, only very few RAKT procedures in children have been described. Kidney transplant recipient patients, being immunocompromised, might be at increased risk for perioperative surgical complications, which creates additional challenges in management. Applying techniques of minimally invasive surgery may contribute to the improvement of clinical outcomes for the pediatric transplant patients population and help mitigate the morbidity of KT. However, many challenges remain ahead. Minimally invasive surgery has been consistently shown to produce improved clinical outcomes as compared to open surgery equivalents. Robot-assisted laparoscopic surgery (RALS) has been able to overcome many restrictions of classical laparoscopy, particularly in complex and demanding surgical procedures. Despite the presence of these improvements, many challenges lie ahead in the surgical and technical-material realms, in addition to anesthetic and economic considerations. RALS in children poses additional challenges to both the surgical and anesthesiology team, due to specific characteristics such as a small abdominal cavity and a reduced circulating blood volume. Cost-effectiveness, esthetic and functional wound outcomes, minimal age and weight to undergo RALS and effect of RAKT on graft function are discussed. Although data on RAKT in children is scarce, it is a safe and feasible procedure and results in excellent graft function. It should only be performed by a RAKT team experienced in both RALS and transplantation surgery, fully supported by a pediatric nephrology and anesthesiology team. Further research is necessary to better determine the value of the robotic approach as compared to the laparoscopic and open approach. Cost-effectiveness will remain an important subject of debate and is in need of further evaluation as well

Robot-assisted Kidney Transplantation: The European Experience.

BACKGROUND: Robot-assisted kidney transplantation (RAKT) has recently been introduced to reduce the morbidity of open kidney transplantation (KT). OBJECTIVE: To evaluate perioperative and early postoperative RAKT outcomes. DESIGN, SETTING AND PARTICIPANTS: This was a multicenter prospective observational study of 120 patients who underwent RAKT, predominantly with a living donor kidney, in eight European institutions between July 2015 and May 2017, with minimum follow-up of 1 mo. The robot-assisted surgical steps were transperitoneal dissection of the external iliac vessels, venous/arterial anastomosis, graft retroperitonealization, and ureterovesical anastomosis. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS: Descriptive analysis of surgical data and their correlations with functional outcomes. RESULTS AND LIMITATIONS: The median operative and vascular suture time was 250 and 38min, respectively. The median estimated blood loss was 150ml. No major intraoperative complications occurred, although two patients needed open conversion. The median postoperative estimated glomerular filtration rate was 21.2, 45.0, 52.6, and 58.0ml/min on postoperative day 1, 3, 7, and 30, respectively. Both early and late graft function were not related to overall operating time or rewarming time. Five cases of delayed graft function (4.2%) were reported. One case (0.8%) of wound infection, three cases (2.5%) of ileus, and four cases of bleeding (3.3%; three of which required blood transfusion), managed conservatively, were observed. One case (0.8%) of deep venous thrombosis, one case (0.8%) of lymphocele, and three cases (2.5%) of transplantectomy due to massive arterial thrombosis were recorded. In five cases (4.2%), surgical exploration was performed for intraperitoneal hematoma. Limitations of the study include selection bias, the lack of an open control group, and failure to report on patient cosmetic satisfaction. CONCLUSIONS: When performed by surgeons with robotic and KT experience, RAKT is safe and reproducible in selected cases and yields excellent graft function. PATIENT SUMMARY: We present the largest reported series on robot-assisted kidney transplantation. Use of a robotic technique can yield low complication rates, rapid recovery, and excellent graft function. Further investigations need to confirm our promising data

Discrimination, Reliability, Sensitivity, and Specificity of Robotic Surgical Proficiency Assessment With Global Evaluative Assessment of Robotic Skills and Binary Scoring Metrics: Results From a Randomized Controlled Trial

Objective: To compare binary metrics and Global Evaluative Assessment of Robotic Skills (GEARS) evaluations of training outcome assessments for reliability, sensitivity, and specificity. Background: GEARS–Likert-scale skills assessment are a widely accepted tool for robotic surgical training outcome evaluations. Proficiency-based progression (PBP) training is another methodology but uses binary performance metrics for evaluations. Methods: In a prospective, randomized, and blinded study, we compared conventional with PBP training for a robotic suturing, knot-tying anastomosis task. Thirty-six surgical residents from 16 Belgium residency programs were randomized. In the skills laboratory, the PBP group trained until they demonstrated a quantitatively defined proficiency benchmark. The conventional group were yoked to the same training time but without the proficiency requirement. The final trial was video recorded and assessed with binary metrics and GEARS by robotic surgeons blinded to individual, group, and residency program. Sensitivity and specificity of the two assessment methods were evaluated with area under the curve (AUC) and receiver operating characteristics (ROC) curves. Results: The PBP group made 42% fewer objectively assessed performance errors than the conventional group (P &lt; 0.001) and scored 15% better on the GEARS assessment (P = 0.033). The mean interrater reliability for binary metrics and GEARS was 0.87 and 0.38, respectively. Binary total error metrics AUC was 97% and for GEARS 85%. With a sensitivity threshold of 0.8, false positives rates were 3% and 25% for, respectively, the binary and GEARS assessments. Conclusions: Binary metrics for scoring a robotic VUA task demonstrated better psychometric properties than the GEARS assessment. </jats:sec