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6 Annual th

MIRA Congress
“Robotics Surgery Marathon: Clinical Practice, Education & the Simulation Olympics”
May 11-13, 2011 Athens, Greece Hilton Athens

MIRA President: Jacques Hubert, MD Participation from:


Program Chair: Ivo Broeders, MD The Clinical Robotic Surgery Association (CRSA)
Congress President: Konstantinos Konstantinidis, MD The Society of Robotics Surgery (SRS)
Program Co-Chair: Savas Hiridis, MD The Hellenic Scientific Society of Robotic Surgery
New Technology Demonstrations at the
Intuitive Surgical Booth
Single-Site™ Instrumentation
for the da Vinci® Si™ Surgical System

Hands on demonstrations and 1st clinical experience footage

This product has received CE mark but is not cleared by the FDA

The da Vinci Skills Simulator™


Skills practice in an immersive virtual environment

Schedule subject to change. While clinical studies support the use of the da Vinci Surgical System as an effective tool for minimally invasive surgery, individual results may vary. Before performing any clinical
procedure utilizing the System, physicians are responsible for receiving sufficient training and proctoring to ensure that they have the requisite training, skill, and experience necessary to protect the health and
safety of the patient. For technical information, including full cautions and warnings on using the da Vinci System, please refer to the System User Manual. Read all instructions carefully. Failure to properly follow
instructions, notes, cautions, warnings, and danger messages associated with this equipment may lead to serious injury or complications for the patient. © 2011 Intuitive Surgical. All rights reserved. Intuitive, Intui-
tive Surgical, da Vinci, da Vinci S HD, da Vinci Si, InSite, TilePro and EndoWrist are trademarks or registered trademarks of Intuitive Surgical. All other product names are trademarks or registered trademarks of their
respective holders. PN 874434 Rev A 4/11
Welcome GENERAL INFORMATION
On behalf of the organizing committee of the MIRA 2011 COURSE DESCRIPTION
Congress, it is my pleasure to welcome you to the 6th International The 6th International Congress will feature state of the art lectures,
Congress on Robotic Surgery. 4 Post-Graduate Courses, a Business Class Course, and internationally
The purpose of the 6th International Congress is to bring together renowned faculty. This activity offers an extensive update on the
surgeons of all specialties, internists, basic science and clinical advancements within minimally invasive robotic procedures.
researchers and engineers from around the world to discuss the
state-of-the-art in robotic surgical techniques and to set the OBJECTIVES
directions and trends for its future improvements. At the conclusion of this activity, participants should be able to:
We are delighted that most of the world leaders in the field will be • Educate in detail the new robotic surgical teams in well-established
present. This will be a timely meeting to set or reset the goals of procedures in General Surgery, Urology, Gynecology and Cardiothoracic
Robotic Surgical Clinical Programs for future years. during the Postgraduate Course sessions.
• Address current applications of robotics in various specialties of surgery and
It will also be a unique opportunity for students, residents and interns
assess clinical efficiency and safety.
to learn about robotic surgery and interact with world experts.
• Present latest innovations of the technology with new instrumentation, better
A variety of social activities will give you the opportunity to meet ergonomics and different concepts such as single-port robotics.
friends, enjoy the traditional Greek music, food, dancing and • Introduce future trends in research level such as novel robotic systems,
hospitality. The historical city of Athens, the birthplace of Socrates microrobotics, intraoperative navigation and augmented reality and
and Plato, the home of philosophy, democracy and culture, is an immunofluorecence lymph node visualization.
ideal setting for providing such an atmosphere and environment.
We are looking forward to see you all in Greece for a glorious 2011 TARGET AUDIENCE
meeting! The target audience for this activity includes: surgeons, internists,
K.M.Konstantinidis, MD, PhD, FACS, radiologists, engineers and computer scientists who are interested in
The MIRA 2011 Congress President robotics, telerobotics, telepresences, teleconferencing and telementoring.

CONTACT INFORMATION
MIRA: 11300 West Olympic Blvd., Ste. 600, Los Angeles, CA, USA 90064
Phone: +1.310.424.3353, ext. 125 | Email: Maribeth@mirasurgery.org
SPEAKER PREP/
REG HOURS Ikaria/Middle Lobby (Convention Level) OFFICIAL CONGRESS HOTEL INFORMATION
Wednesday, May 11, 2011 10:00am-7:00pm Hilton Athens: 46 Vassilissis Sofias Avenue, Athens, Greece 11528
Thursday, May 12, 2011 7:30am-8:00pm Phone: +30.210.7281000 | Fax: +30.210.7281111
Friday, May 13, 2011 7:30am-8:00pm
WHY JOIN MIRA?
EXHIBIT & POSTER HOURS Terpsichore D/Erato • Interaction with leaders on the cutting edge of minimally invasive robotic
Wednesday, May 11, 2011 7:00pm-8:30pm interventions and techniques.
Welcome Reception in Exhibit Hall
• An international membership dedicated to providing the best diagnostic and
Thursday, May 12, 2011 10:30am-4:30pm
therapeutic care possible, even in distant and remote places.
Friday, May 13, 2011 9:30am-4:00pm
• The sharing of knowledge with a multidisciplinary group of professionals,
Make sure to sign up for your chance to compete in the Robotic including surgeons, internists, radiologists, engineers and computer scientists
Olympics Contest! Sign up sheets can be found at the registration desk and who are developing and using minimally invasive robotics.
participants are encouraged to compete throughout the Congress.The top 8 • The opportunity to contribute to innovations, integration and implementation
finalists will compete for the Gold Medal on Friday, May 13, 2011! of future developments in areas such as NOTES and Solo Surgery.
• An opportunity to contribute in organizing the training and establishing
requirements for credentialing.
TABLE OF CONTENTS • A subscription to The International Journal of Medical Robotics and
General Information 1 Computer Assisted Surgery journal included in the annual membership dues.
About Athens, Greece 2 • The advantage to attend our meetings at the lower member registration fees.
Meeting Leadership & Invited Faculty 2
Please visit www.mirasurgery.org/membership.php to become a
MIRA Board Members 4
member today!
Meeting Committees 4
Floorplan 5 ABOUT MIRA
Exhibitors 5 MIRA was founded under the sky of Tuscany, Italy, in June 2004,
Schedule-at-a-Glance 6 as a result of a discussion among experts, sharing their experiences,
Scientific Program 7 problems, technical details, and perspectives.
Oral Abstracts 13
Video Abstracts 28 MIRA is a multidisciplinary association that provides multi-specialty
Poster List 32 forums to present new advances and clinical outcomes in all aspects of
Poster Abstracts 36 robotic surgery.
MIRA Membership Application 61
www.mirasurgery.org 1
about Meeting Leadership & Invited Faculty
ATHENS, GREECE
MEETING LEADERSHIP
GENERAL INFORMATION
Athens is renowned all over the world for its
millenary history, for spreading art, culture, science
and philosophy throughout, thus being the cradle
of modern western civilization. The city presents
a unique combination of the ancient history
and modern world, and offers an unforgettable
Mediterranean experience to all its visitors. The ideal MIRA President: Program Chair:
climate, the great hospitality, the rich transportation Jacques Hubert, MD Ivo Broeders, MD
network, the unique combination between
business and pleasure, the fully renovated meeting
infrastructure, as well as the great variety of cultural
and entertainment options can be a few of the city’s
advantages. Actually, Athens has a proud tradition of
hosting great medical and scientific events. Congress President:
Konstantinos Program Co-Chair:
GETTING TO THE CONGRESS HOTEL Konstandtinidis, MD Savas Hiridis, MD
The airport is located 33 km southeast of Athens and is
easily accessible via Attiki Odos, a six-lane motorway
(the Athens City Ring Road). Public transportation to INVITED FACULTY
Athens and the Port of Piraeus is provided by express Abdulrahman Albassam, MD Gunjal Garg
airport bus connections on a 24-hour basis, while a King Khalid University Hospital Wayne State University, Detroit Medical Center
direct Metro line connects the airport with the city Mehran Anvari, MD Changqing Gao, MD
centre (Syntagma square) in 27 minutes. Professor of Surgery, Chair in Minimally PLA General Hospital
Invasive Surgery & Surgical Innovation, Professor Evangelos Georgiou, MD,
The Congress hotel, Hilton Athens, is also
McMaster University, Canada PhD
connected to the airport via the blue line and
is located close to Evangelismos station. Vassilis Apostolopoulos, PhD Athens University Medical School, Athens,
Athens Medical Group, CEO, Athens, Greece Greece
A taxi ride from the airport to the city centre and
the Congress venue costs between 26-40 Euros. Nikos Aspragathos Farid Gharagozloo, MD
Professor, University of Patras, Patras, Greece Institute of Thoracic and Cardiovascular
Duration approximately 40 minutes. Masoud Azodi, MD Surgery, George Washington University
Yale-New Haven Hospital Medical Center, Washington, DC, USA
Climate: Temperate, mild winter, warm, dry
summer. The average daytime temperature in May Scott J Belsley, MD George Giannopoulos, MD
can vary between 12°C and 20°C. St. Luke’s-Roosevelt Hospital Center Yonsei University College of Medicine
Language: The native language is Modern Greek. Nikolaos Bonaros Piero Giulianotti, MD, FACS
English is widely spoken as a second language by Innsbruck Medical University Professor of Surgery, Chief, Division of
Minimally Invasive, General & Robotic
the majority of Greeks, while French and German Johannes Bonatti, MD Surgery, University of Illinois at Chicago,
are also spoken at a good extent. University of Maryland, Baltimore, MD, USA Chicago, IL, USA
Time: Greece is two hours ahead of Greenwich Mean Prof. Ivo A.M.J. Broeders MD, Prof. Grigor Gorchev, MD, PhD,
Time GMT+2 PhD DSc
University Twente,Technical Medicine, Medical University Pleven, Pieven, Bulgaria
Greece 12:00 – London 10:00 – New York 05:00 –
Meander Medical Center Amersfoort,
Sydney 20:00 The Netherlands Monika E. Hagen, MD, MBA
Division of Digestive Surgery, University
Electricity: The electricity current in Greece Vasiliki Chatzirafail Hospital Geneva, Geneva, Switzerland, &
is 220v, 50Hz and the socket type is Europena Director of Gyn Department, Euroclic, Intuitive Surgical, Sunnyvale, CA, USA
Standard. Athens, Greece
Dong-Seok Han, MD
Smoking Policy: Starting from July 1st 2009 Pericles-J Chrysoheris, MD Department of Surgery, Cancer Research
smoking is prohibited by the law at all indoor Athens Medical Center, Athens, Greece Institute, Seoul National University, College
public areas in Greece. Professor Woong Youn Chung of Medicine
Health: Emergency treatment is free to all – Department of Surgery, Yonsei University Georgios E. Hilaris, MD, FACOG
natives and visitors alike – in public hospitals. There College of Medicine, Seoul, Korea Department of Laparoscopic & Robotic
are more doctors per person in Greece than in Michael A Conditt, PhD Surgery and Gynecologic Oncology, Hygeia
most other counties in the European Union. MAKO Surgical Corp and IASO Medical Centers, Athens, Greece
Adjunct Clinical Instructor of Obstetrics and
Currency: Greece is a full member of the Jose Manuel Fort, PhD Gynecology, Stanford University, Palo Alto,
European Union since 1981, and its currency is Universitary Hospital Vall d’Hebron CA, USA
the Euro (€). All major credit cards are widely Taryn N Gallo, MD
accepted in Greece. Yale New Haven Health/Bridgeport Hospital
2 6 TH ANNUAL MIRA CONGRESS May 11-13, 2011
Savas C. Hiridis MD, MSc Dimitrios Linos, MD, FACS Francois Pugin, MD
Athens Medical Center, Athens, Greece Consultant in Surgery Massachusetts General Hospital, University Hospitals Geneva
Petros C Hiridis, MD Lecturer on Surgery Harvard Medical School, Director Ryan Rhodes
Athens Medical Center, Athens, Greece of Surgery, Hygeia Hospital, Athens, Greece Vice-President, Clinical Marketing,
Abolfazl Hosseini, MD, PhD Michael Litos, MD, PhD, MRCOG Intuitive Surgical, Inc, Sunnyvale, CA
Dept of Urology, Karolinska University Hospital Euroclinic, Athens, Greece Emilio Ruiz Morales
Stockholm, Sweden Fabrizio Luca, MD Eur Ing- Head, ALF-X Surgical Robotics Department
Jacques Hubert, MD European Institute of Oncology, Milano, Italy SOFAR S.p.A., Milan, Italy
Professor of Urology, Head of the Urology John Lymer, PEng Richard M. Satava, MD
Department, University Hospital of Nancy Chief Engineer, MDA, Brampton ON Canada Professor, Department of Surgery, University of
Chu Nancy - Brabois, Nancy, France Washington Medical Center, Seattle, Washington, USA
John J. Meehan, MD, FACS
N Hubert, MD Co-Director, Seattle Children’s International Robotic Dan-Arin Silasi, MD
Urology Dept., CHU de Nancy-Brabois Surgery Center, Seattle Children’s Hospital Yale New Haven Health/Bridgeport Hospital
Woo Jin Hyung, MD PhD University of Washington, Seattle, Washington, USA Giuseppe Spinoglio, MD
Yonsei University College of Medicine Jonathan J Melquist, MD Division of Oncologic General Surgery,
Bob Kiaii, MD Stony Brook University Medical Center General Hospital, Alessandria, Italy
London, Ontario Canada John S. Missanelli, DO Michael Stark, MD, President
C.E. Iselin, MD Sharp Grossmont Hospital, La Mesa, CA, USA New European Surgical Academy, Berlin, Germany
Professor and Chief, Urology Clinic, Geneva Konstantinos Myrillas, MRCOG Maarten Steinbuch, Prof. Dr.
University Hospital, Geneva, Switzerland Athens, Greece Eindhoven University of Technology, The Netherlands
Sang-Wook Kang, MD Zbigniew Nawrat, MD Chung Ngai Tang, MBBS FRCS
Yonsei University College of Medicine Foudation of Cardiac Suregry Development Department of Surgery, Pamela Youde Nethersole
Vasilis Kapetanakis, MD Vincent Obias, MD Eastern Hospital
Mayo Clinic, IASO Medical Centers' George Washington University Eugene P. Toy, MD
Hyoung-Il Kim, MD Mona Orady, MD University of Rochester
Department of Surgery, Institute of Gastroenterology, Division of Minimally Invasive Gynecology and N. van der Stap, BS
and Cancer Metastasis Research Center, Yonsei Robotic Surgery, Department of Obstetrics, University of Twente, Meander Medical Center
University College of Medicine Gynecology, and Women’s Health, Henry Ford Prof. Dr. Richard Van Hillegersberg
Jin C. Kim, MD Health System Department of Surgery, University Medical Utrecht
University of Ulsan College of Medicine and Asan Elena Ortiz Oshiro, MD, PhD The Netherlands
Medical Center Hospital Clinico San Carlos, Universidad Catalin Vasilescu, Assoc. Prof., PhD
Se-Heon Kim, MD Complutense de Madrid Fundeni Institute of Digestive Disease and Liver
Yonsei University College of Medicine, Seoul, Korea Emanuel Panagiotou, MD, FACS Transplantation
Konstantinos M. Konstantinidis, MD, Diplomate of the American Board of Urology Roy Verhage, MD
PhD, FACS Director Urology clinic, Robotic Urology, Hygeia University Medical Center Utrecht
Athens Medical Center, Athens, Greece Hospital, Athens, Greece
C. Waked, MD PhD
N Kuperij, BSc Aristotelis Panos, MD, PhD, FECTS Dept. of Urology and Nephrology,
University of Twente, Department of Technical 3rd Clinic for Cardiac Surgery, Hygeia Hospital CHU Nancy-Brabois
Medicine, University of Twente Athens, Greece
Professor Paul Alan Wetter
Apostolos P. Labanaris, MD, PhD Harilaos Pappis, MD, PhD, FACS Chairman, Society of Laparoendoscopic Surgeons,
Department of Urology and Pediatric Urology, Prostate Head 3rd Surgical Dept. Hygeia Hospital Professor Emeritus, University of Miami School of
Center Northwest, St. Antonius Medical Center Athens, Greece Medicine, Miami, Florida, USAEric B. Wilson, MD
Professor Georges Lawson, MD Jae Hyun Park UTHealth Medical School, Houston, TX, USA
ORL- Head & Neck Surgery, Clinique Universitaires University of Ulsan College of Medicine Yanghee Woo, MD
UCL de Mont Godine, Yvoir, Belgium C. Perrenot, MD Department of Surgery, Robot and Minimally Invasive
Jandee Lee, MD, PhD Urology Dept & IADI, CHU Nancy-Brabois Surgery Center, Yonsei University College of Medicine
Yonsei University College of Medicine Alessio Pigazzi, MD, PhD Hong Man Yoon, MD
Sohee Lee City of Hope National Medical Center, Dept of Research Institute and Hospital, National Cancer
Department of Surgery, Yonsei University Health System General Oncologic Surgery, Duarte, CA Center
Eric J Lehr, MD, PhD Irinel Popescu, MD, PhD, FACS Ningxin Zhou
University of Maryland School of Medicine Fundeni Institute of Digestive Diseases and Liver Institute of Hepatobiliary & Gastrointestinal
Medizinische Universität Innsbruck Transplantation Diseases, PLA Second Artillery General Hospital
Mario M Leitao, MD Vassilis Poulakis, MD, PhD, FEBU
Memorial Sloan-Kettering Cancer Center Associate Professor at the University of Frankfurt, Germany
Urology Clinic of Doctors’ Hospital, Athens, Greece
Fiona Lindo, MD
Yale New Haven Health/Bridgeport Hospital
www.mirasurgery.org 3
meeting leadership Meeting committees
MIRA Board Members
MIRA PROGRAM LOCAL SCIENTIFIC LOCAL MEDICAL
Mehran Anvari, MD COMMITTEE COMMITTEE STUDENT
Past-President, Hamilton, Ontario, Canada Ivo Broeders K. Anastasakou COMMITTEE
Garth Ballantyne, MD Savas Hiridis N. Andriopoulos A. Bogiatzopoulou
Past-President, Hackensack, NJ, USA Santiago Horgan N. Aspragathos K. Dakis
Robert Kiaii G. Basdanis J. Dimovelis
Johannes Bonatti, MD George Lawson Ch. Charitopoulos A. Dovolou
President-Elect, Baltimore, MD, USA Ch. Georgakopoulos
Javier Magrina G. Chilaris
Ivo A. M. J. Broeders, MD Marc Margolis Th. Diamandis K. Imbrialos
Vice President, Utrecht,The Netherlands John Meehan Ch. Efthimiadis Th. Katsichtis
Arnold Byers, MD Dmitry Oleynikov P. Feretos S. Korre
Board Member, Hackensack, NJ, USA Alessio Pigazzi P. Gavriil A. Koutis
Ash Tewari E. Georgiou A. Michalinos
James Fleshman, MD
V. Hadjirafail K. Mitsakou
Board Member, St. Louis, MI, USA LOCAL V. Kapetanakis K. Mpananis
Changqing Gao, MD ORGANIZING K. A. Konstantinidis I. Pentara
Board Member, Beijing, China COMMITTEE D. Koutsouris K. Psatha
Farid Gharagozloo, MD F. Antonakopoulos D. Linos M. Sideris
Board Member,Washington, DC, USA P. Chrysoheris K. Myrillas I. Tsiakas
M. Georgiou N. Nikiteas A. Tzeortzopoulou
Indi Gill, MD P. Hiridis
Board Member, Los Angeles, CA, USA E. Panagiotou S. Vasiliou
D. Mousiolis A. Panos A. Vlachou
Santiago Horgan, MD Ch. Pappis A. Zouridis
Past-President, San Diego, CA, USA N. Pardalidis
Jacques Hubert, MD G. Pistofidis
President, Nancy, France Ach. Ploumidis
Woo Jin Hyung, MD Ant. Ploumidis
Board Member, Seoul, Korea V. Poulakis
G. Sambalis
Camran Nezhat, MD
D. Tsakagiannis
Board Member, Palo Alto, CA, USA
Ch. Tsigris
Dmitry Olyenikov, MD K. Tzafestas
Board Member, Omaha, NE, USA M. Vorias
Sonia Ramamoorthy, MD A. Xiarchos
Treasurer, La Jolla, CA, USA G. K. Zografos
Richard Satava, MD G. N. Zografos
Board Member, Seattle,WA, USA
Ash Tewari, MD
Secretary, NewYork, NY, USA

MIRA 2011 MEETING CORPORATE SUPPORTERS

Diamond Donor Gold Donor Silver Donor

Meeting Sponsors
Postgraduate Course Sponsor

4 6 TH ANNUAL MIRA CONGRESS May 11-13, 2011


HOTEL FLOORPLAN MIRA 2011
EXHIBITORS
CONVENTION LEVEL

POOL LEVEL

www.mirasurgery.org 5
Schedule-at-a-Glance Faculty subject to change
WEDNESDAY, MAY 11, 2011
10:00am-6:00pm Registration/Speaker Prep Middle Lobby (Convention Level)
12:00pm-6:00pm Postgraduate Courses
1) Urology: Radical Prostatectomy, Cystectomy and Partial Nephrectomy Santorini 1
2) Gynecology: Complex Surgery for Benign and Malignant Gynecologic Disorders Thalia 4
3) Colo-Rectal Surgery: Robotic (Para)rectal Dissection Santorini 2
4) Cardio-Thoracic Surgery: Malignant and Benign Disorders of Lung and Esophagus Thalia 3
3:00pm-7:00pm Business Class Meeting Terpsichore ABC
7:00pm-8:30pm Welcome Reception in Exhibit Hall Terpsichore D/Erato
THURSDAY, MAY 12, 2011
7:30am Registration/Coffee & Tea Middle Lobby (Convention Level)
8:30am-11:20am Plenary Session Terpsichore ABC
8:30am Welcome/Presidential Address – Jacques Hubert, MD
9:00am Keynote Lecture: From Hippocrates to da Vinci – Konstantinos Konstantinidis, MD
9:30am Advances in Clinical Robotics: The Year 2010-2011 Part I
11:20am Coffee & Tea Break in Exhibit Hall Terpshichore D/Erato
11:40am From Experiment to Clinic: What’s Coming? Terpshichore ABC
1:20pm Lunch on own/Exhibits & Posters Open Terpsichore D/Erato
2:00pm-4:00pm Concurrent Sessions
SS01: General Surgery I Terpsichore ABC
SS02: General Surgery II Thalia 3
SS03: Urology (2:00pm-3:00pm)/SS04: Cardio-Thoracic (3:00pm-4:00pm) Thalia 4
4:00pm Coffee& Tea Break in Exhibit Hall Terpsichore D/Erato
4:30pm-5:30pm Concurrent Sessions and Video Sessions
SS05: General Surgery Terpsichore ABC
SS06: Gynecology Thalia 3
SS07: Urology/Thoracic/Pediatric/Miscellaneous Thalia 4
5:30pm-6:00pm Keynote Lecture: Intuitive Surgical and the Future of Robotic Surgery
Ryan Rhodes, Vice-President, Clinical Marketing, Intuitive Surgical, Inc
6:00pm Grand Opening Ceremony
Congress President: Dr. Konstantinidis
Welcome message from governmental and academic authorities.
8:30pm Gala Dinner: Dreams Asteras Seaside
Shuttles will depart from the Hilton Athens at 8:00pm. Shuttles will be available as of 10:00pm to bring participants back to the hotel.
Please note that guests are welcome for a fee. Space is limited so please visit registration for more information and tickets.
FRIDAY, MAY 13, 2011
7:30am Registration/Coffee & Tea Outside Terpsichore ABC
8:00am-8:30pm MIRA Business Meeting (All Members Welcome) Terpsichore ABC
8:30am-10:00am Robotics in Space Terpsichore ABC
10:00am Coffee& Tea Break in Exhibit Hall Terpsichore D/Erato
10:15am-11:15am Single Incision Symposium Terpsichore ABC
11:15am-1:30pm Advances in Clinical Robotics: The Year 2010-2011 Part II Terpsichore ABC
1:30pm-2:30pm Lunch on own Exhibits & Posters Open Terpsichore D/Erato
2:30pm-3:30pm Concurrent Sessions
SS08: Gynecology Terpsichore ABC
SS09: Pediatric Surgery and TORS Thalia 3
SS10: Novel Applications - Simulation, Research & Miscellaneous Thalia 4
3:30pm Coffee& Tea Break in Exhibit Hall Terpsichore D/Erato
3:45pm-5:00pm Plenary Best Abstract and Video Session Terpsichore ABC
5:00pm Coffee & Tea Break Terpsichore D/Erato
5:15pm-6:15pm The Robotic Olympic Live Contest Terpsichore ABC
6:15pm-7:00pm Robotics in Surgery: Where Are We Heading? – Richard Satava, MD Terpsichore ABC
7:00pm-8:00pm Closing Lectures: Past President, President and Closing Remarks from Congress President Terpsichore ABC
8:00pm Congress Adjourned
6 6 TH ANNUAL MIRA CONGRESS May 11-13, 2011
SCIENTIFIC PROGRAM
WEDNESDAY, MAY 11, 2011
12:00pm-6:00pm POSTGRADUATE COURSES
1) Urology: Radical Prostatectomy, Cystectomy and Partial Nephrectomy /Santorini 1 Santorini 1
Chair: Jacques Hubert, MD
Co-Chairs: A.Hosseini, MD & Christope Iselin
12:00pm-12:20pm Introduction: Robotics in Urology – Jacques Hubert, MD
12:20pm-1:20pm Robotic Pelvic Surgery: Principles – Christophe Iselin, E. Panagiotou, MD, A. Hosseini, & N. Pardalidis, MD
1:20pm-1:40pm Coffee & Tea Break
1:40pm-2:40pm Robotic Radical Prostatectomy – Christophe Iselin, MD & Emannouel Panagiotou, MD
2:40pm-3:40pm Robotic Radical Cystectomy with Neobladder Formations – Abbi Hosseini, MD & Nikolaos P. Pardalidis, MD
3:40pm-4:00pm Coffee & Tea Break
4:00pm-5:40pm Renal Surgery UPJ – Christophe Iselin & Nikolaos Pardalidis, MD
Radical, Partial Nephrectomy & Donor Nephrectomy – Jacques Hubert, MD
5:40pm-6:00pm Questions & Discussion

2) Gynecology: Complex Surgery for Benign and Malignant Gynecologic Disorders Thalia 4
Chair: Grigor Gorchev, MD, PhD, DSc
Co-Chair: Konstantinos Myrillas, MD
12:00pm-12:20pm Introduction: State of the Art in Robotic Gynecology – Petros Hirides, MD, PhD
12:20pm-1:20pm Robotic Total Hysterectomy and Lymph Node Harvesting – Grigor Gorchev, MD, PhD, DSc
1:20pm-1:40pm Coffee & Tea Break
1:40pm-2:40pm Robotic Excision of Uterine Fibromas – Konstantinos Myrillas, MD
2:40pm-3:40pm Robotic-Assisted Laparoscopic Sacrocolpopexy and Cervicosacropexy – David M. Kimble, MD
3:40pm-4:00pm Coffee & Tea Break
4:00pm-4:50pm Robotic Tubal & Ovarian Procedures – Konstantinos Myrillas, MD
4:50pm-5:40pm Colpoteres Suspension Procedure – John S. Missanelli, DO
5:40pm-6:00pm Questions & Discussion

3) Colo-Rectal Surgery: Robotic (Para)rectal Dissection Santorini 2


Chair: Fabrizio Luca, MD
Co-Chair: Pericles-J Chrysoheris, MD
12:00pm-12:20pm Introduction: State of the Art in Robotic Colorectal Surgery – Pericles-J Chrysoheris, MD
12:20pm-12:40pm Robotic Right Colectomy for Cancer – Giuseppe Spinoglio, MD
12:40pm-1:00pm Robotic Left Colectomy for Cancer – Savas Hiridis, MD
1:00pm-1:10pm Panel Discussion – Faculty
1:10pm-1:50pm Coffee & Tea Break
1:50pm-2:10pm Robotic Anterior Resection of the Rectum: Hybrid Technique. Patient Positioning,
Trocar Placement, Procedure Step by Step – Alessio Pigazzi, MD
2:10pm -2:30pm Robotic Anterior Resection of the Rectum: Full Robotic Single Position Technique.
Patient Positioning, Trocar Placement, Procedure Step by Step – Fabrizio Luca, MD
2:30pm-2:40pm Panel Discussion – Faculty
2:40pm-3:10pm Robotic Procedures for Rectal Cancer – Alessio Pigazzi, MD
3:10pm-3:30pm Robotic Total Mesorectal Excision: The Key Points for Autonomic Nerve Preservation – Fabrizio Luca, MD
3:30pm-3:40pm Panel Discussion – Faculty
3:40pm-4:00pm Single port colectomy – Vincent Obias, MD
4:00pm-4:20pm Coffee & Tea Break
4:20pm-4:40pm Robotic Treatment of Benign Colo-Rectal Diseases – Vincent Obias, MD
4:40pm-5:00pm Robotic Colorectal Oncology Concerns – Alessio Pigazzi, MD
5:00pm-5:30pm Questions & Discussion

www.mirasurgery.org 7
SCIENTIFIC PROGRAM
4) Cardio-Thoracic Surgery: Malignant and Benign Disorders of Lung and Esophagus Thalia 3
Chair: Farid Gharagozloo, MD
Co-Chair: Richard van Hiiligersberg, MD
12:00pm-12:40pm Robotically Assisted Coronary Artery Bypass Grafting – Johannes Bonatti, MD
12:40pm-1:20pm Robotic-Assisted Thoracoscopic Lobectomy for Lung Cancer – Farid Gharagozloo, MD
1:20pm-1:40pm Coffee & Tea Break
1:40pm-2:40pm Robot-Assisted Thoracoscopic Esophagectomy for Cancer – Richard van Hiiligersberg, MD
2:40pm-3:40pm Robot-Assisted Thoracoscopic Excision of Mediastinal Tumors – Farid Gharagozloo, MD
3:40pm-4:00pm Coffee & Tea Break
4:00pm-5:00pm Advances in Robotic Cardiac Surgery – Bob Kiaii, MD
5:00pm-5:30pm Questions & Discussion
Postgraduate courses are supported by a grant from Athens Medical Centre.

3:00pm-7:00pm BUSINESS CLASS MEETING Terpsichore ABC


Moderators: Ivo Broeders, MD & Ryan Rhodes
3:00pm-3:30pm Launching A Da Vinci Program: A Multi-Stakeholder Process – Ivo Broders, MD
3:30pm-4:00pm The Value of New Developments for the Da Vinci Marketing Plan – Monika Hagen, MD
4:00pm-5:00pm Investment Business Plan for a Robotic Surgery Program – Vassilios Apostolopoulos, CEO of Athens Medical Group
5:00pm-5:30pm Robotic Surgery Program in Athens Medical Center. How Far and How Soon – Konstantinos Konstantinidis, MD
5:30pm-6:00pm Establishment of a New Robotic Surgical Program at a University Center: The Romanian Experience – Irinel Popescu, MD
6:00pm-7:00pm Guidelines for Initiation of a Successful Robotic Surgery Program – Ryan Rhodes, Vice-President, Clinical Marketing, Intuitive Surgical, Inc

7:00pm-8:30pm Welcome Reception Terpsichore D/Erato


THURSDAY, MAY 12, 2011
8:00am Registration/Coffee & Tea Middle Lobby (Convention Level)

8:30am-11:20am PLENARY SESSION Terpsichore ABC


Moderators: Fabrizio Luca, MD & Dimitrios Linos, MD, FACS
8:30am-9:00am Welcome/Presidential Address – Jacques Hubert, MD
9:00am-9:30am Keynote Lecture: From Hippocrates To da Vinci – Konstantinos Konstantinidis, MD
Introduced by: Ivo Broeders, MD
Advances in Clinical Robotics: The Year 2010-2011 Part I
9:30am-9:50am Advances in Pediatric Surgery – John J. Meehan, MD, FACS
9:50am-10:10am Benign and Malignant Gynecologic Disorders – Grigor Gorchev, MD , PhD, DSc
10:10am-10:30am Advances in Rectal Cancer – Alessio Pigazzi, MD, PhD
10:30am-10:50am Bariatric Surgery – Eric B.Wilson, MD
10:50am-11:20am The Transaxillary Thyroidectomy – Woong Youn Chung

11:20am-11:40 am Coffee & Tea Break Terpsichore D

11:40am-1:20pm PLENARY SESSION Terpsichore ABC


Moderators: Evangelos Georgiou, MD, PhD & Ivo Broeders, MD
From Experiment to Clinic: What’s Coming?
11:40am-12:00pm The Raven Robotic Surgical System – Michael Stark & Emilio Ruiz Morales, Eur Ing
12:00pm-12:20pm Sofie: Concept of a Table Mounted Three Armed Robot – Maarten Steinbuch, MD
12:20pm-12:40pm Mimic: from Table Top to Console – Jacques Hubert, MD
12:40pm-1:00pm Telemanipulation of Flexible Instruments – Ivo Broeders, MD
1:00pm-1:20pm Questions & Discussion

1:20pm Lunch on own/Exhibits & Posters Opens

2:00pm-4:00pm CONCURRENT SESSIONS


SS01: General Surgery I Terpsichore ABC
Moderator: Nikolaos Nikiteas, MD & Richard Satava, MD
S001: ROBOTIC VERSUS ENDOSCOPIC THYROIDECTOMY FOR THYROID CANCERS: A MULTI-INSTITUTIONAL ANALYSIS OF EARLY SURGICAL
OUTCOMES Jandee Lee, MD, PhD, Jong Ho Yun, MD, Kee Hyun Nam, MD, Woong Youn Chung, MD, PhD, Yonsei University College of Medicine

8 6 TH ANNUAL MIRA CONGRESS May 11-13, 2011


S002: INITIAL RESULTS OF ROBOTIC-ASSISTED THYROIDECTOMY THROUGH A GASLESS TRANSAXILLARY APPROACH Andreas
Kiriakopoulos, MD, Efthimios Poulios, MD, Dimitrios Linos, MD, 1st Surgical Clinic, Department of Surgery, Hygeia Hospital, Athens, Greece
S003: THE USEFULNESS OF ROBOTIC THYROIDECTOMY FOR THE MANAGEMENT OF BENIGN THYROID DISEASE George Giannopoulos, MD,
Jae Hyun Park, MD, Jong Ju Jeong, MD, Sang-Wook Kang, MD, Woong Youn Chung, MD, Department of Surgery, Yonsei University College of Medicine
S004: A SURGICAL COMPLETENESS OF ROBOTIC THYROIDECTOMY: A PROSPECTIVE COMPARISON OF THE OPEN CONVENTIONAL
THYROIDECTOMY VERSUS THE ROBOTIC THYROIDECTOMY 1Jae Hyun Park, 2Jong Ho Yoon, 3Chi Young Lim, 1Kyu Hyung Kim, 1Sohee Lee, 1Haeng
Rang Ryu, 1Sang-Wook Kang, 1Jong Ju Jeong, 1Kee-Hyun Nam, 1Woong Youn Chung, 1Cheong Soo Park, 1) Yonsei University College of Medicine, 2) Asan
Medical Center, University of Ulsan College of Medicine, 3) National Health Insurance Corporation Ilsan Hospital
S005: A COMPARATIVE STUDY OF ROBOTIC VERSUS CONVENTIONAL OPEN MODIFIED RADICAL NECK DISSECTION FOR THE PAPILLARY
THYROID CARCINOMA WITH LATERAL NECK NODE METASTASIS Sang-Wook Kang, MD, Kyu Hyung Kim, MD, Jae Hyun Park, MD, So Hee Lee,
MD, Woong Youn Chung, MD, Department of Surgery, Yonsei University College of Medicine
S006: ROBOTIC SURGERY OF SPLENIC CYSTS Catalin Vasilescu, Assoc. Prof., PhD, Stefan Tudor, Dana Elena Giza, Fundeni Institute of Digestive Disease
and Liver Transplantation, Bucharest, Romania
S007: ROBOTIC SINGLE PORT COLON RESECTIONS: INITIAL EXPERIENCE Rami Makhoul, MD, Grace Montenegro, MD, Vincent Obias, MD,
George Washington University
S008: 180 GENERAL SURGERIES UNDER DA VINCI S SYSTEM IN ONE INSTITUTE IN CHINA Ningxin Zhou, Junzhou Chen, Quanda Liu, Xiaodong Zhang,
Qiang Sun, Yu Xie, Qijun Xia, Zhizhong Zhang, Zhenyu Zhu, Institute of Hepatobiliary & Gastrointestinal Diseases, PLA Second Artillery General Hospital
S009: IS THERE ANY ROLE OF ROBOT-ASSISTED SURGERY OVER LAPAROSCOPIC SURGERY FOR GASTRIC CANCER? Young-Woo Kim, PhD,
Hong Man Yoon, MD, Jun Ho Lee, PhD, Keun Won Ryu, PhD, Bang-Ul Eom, MD, Il Ju Choi, PhD, Chan Gyoo Kim, PhD, Soo Jeong Cho, PhD, Jong Seok
Lee, MD, Myeong-Cherl Kook, PhD, Ji Young Rhee, Gastric Cancer Branch, Research Institute and Hospital, National Cancer Center, Korea
S010: ROBOTIC TRANSANAL ABDOMINAL ANORECTAL RESECTION ( TATA) WITH SPHINCTER PRESERVATION FOR CANCER IN THE
DISTAL RECTUM AFTER NEOADJUVANT THERAPY G. Spinoglio, MD, R. Quarati, MD, F. Priora, MD, LM Lenti, PhD, F. Ravazzoni, PhD, V.
Maglione, MD, Division of Oncologic General Surgery, ASO “SS Antonio e Biagio e Cesare Arrigo”, Alessandria, Italy
S011: PEDIATRIC ROBOTIC SURGERY: THE ULTIMATE DIVERSITY John J. Meehan, MD, Seattle Children’s Hospital, University of Washington
S012: ROBOT-ASSISTED TOTAL GASTRECTOMY FOR EARLY GASTRIC CANCER COMPARING WITH LAPAROSCOPY-ASSISTED TOTAL
GASTRECTOMY Young-Woo Kim, PhD, Hong Man Yoon, MD, Jun Ho Lee, PhD, Keun Won Ryu, PhD, Il Ju Choi, PhD, Chan Gyoo Kim, PhD, Soo
Geong Cho, PhD, Jong Seok Lee, PhD, Myeong-Cherl Kook, PhD, Ji Young Rhee, PhD, Young-iee Park, PhD, Gastric Cancer Branch, Research Institute and
Hospital, National Cancer Center,Korea

SS02: General Surgery II Thalia 3


Moderators: Theodore Diamandis & Irinel Popescu, MD
S013: 58 OPERATIONS ON BILIARY MALIGNANT TUMOR UNDER DA VINCI S SYSTEM Ningxin Zhou, Junzhou Chen, Quanda Liu, Xiaodong Zhang,
Tao Zhang, Institute of Hepatobiliary & Gastrointestinal Diseases, PLA Second Artillery General Hospital
S014: ROBOT-ASSISTED PYLORUS PRESERVING GASTRECTOMY FOR GASTRIC CANCER Dong-Seok Han, MD, Yun-Suhk Suh, MD, Seong-Ho
Kong, MD, Hyuk-Joon Lee, MD PhD, Han-Kwang Yang, MD PhD, Department of Surgery1, Cancer Research Institute2 Seoul National University College of
Medicine, Seoul, Korea
S015: COMPARISON OF PERIOPERATIVE OUTCOMEAS BETWEEN CONVENTIONAL TOTAL LAPAROSCOPIC LIVER RESECTION AND
ROBOT-ASSISTED LAPAROSCOPIC LIVER RESECTION Chung Ngai Tang, MBBS FRCS, Eric C.H. Lai, MBChB MRCSEd FRACS, George P.C. Yang,
MBBS MRCSEd FRACS, Oliver C.Y. Chan, MBChB MRCSEd FRCS, Michael K.W. Li, MBBS FRCS, Department of Surgery, Pamela Youde Nethersole
Eastern Hospital, Chai Wan, Hong Kong SAR, China
S016: THE IMPACT OF BODY HABITUS ON SURGICAL OUTCOMES OF TRANSAXILLARY SINGLE-INCISION ROBOTIC THYROIDECTOMY IN
PAPILLARY THYROID MICROCARCINOMA (PTMC) PATIENTS Sohee Lee, Haeng Rang Ryu, Jae Hyun Park, Kyu Hyung Kim, Sang-Wook Kang, Jong
Ju Jeong, Kee-Hyun Nam, Woong Youn Chung, Cheong Soo Park, Department of Surgery, Yonsei University Health System
S017: EXPERIENCE IN 17 CASES OF ROBOTIC LIVER RESECTION Ningxin Zhou, Quanda Liu, Junzhou Chen, Institute of Hepatobiliary &
Gastrointestinal Diseases, PLA Second Artillery General Hospital
S018: ROBOTIC SLEEVE GASTRECTOMY. A BETTER APPROACH FOR THE UPPER GASTRIC DISSECTION Jose Manuel Fort, PhD, Ramon
Vilallonga, PhD, Manel Armengol, PhD, Universitary Hospital Vall d’Hebron, Barcelona
S019: ROBOTIC RECTAL CANCER SURGERY VERSUS LAPAROSCOPIC RECTAL CANCER SURGERY IN A SINGLE CENTER EXPERIENCE:
SHORT TERM OUTCOMES ANALYSIS Irinel Popescu, MD, PhD, FACS, Victor Tomulescu, MD, PhD, Catalin Vasilescu, MD, PhD, Serban Vasile, MD,
Olivia Sgarbura, MD PhD, Vlad Herlea, MD PhD, Fundeni Institute of Digestive Diseases and Liver Transplantation
S020: ROBOTIC GASTRIC BYPASS: REDUCING ANASTOMOTIC COMPLICATIONS Francois Pugin, MD, Pascal Bucher, MD, Monika Hagen, MD,
Nicolas Buchs, MD, Gilles Chassot, MD, Philippe Morel, MD, University Hospitals Geneva
S021: COMPARATIVE EVALUATION BETWEEN THE ROBOTIC AND OPEN ULTRA-LOW ANTERIOR RESECTION IN PATIENTS WITH LOWER
RECTAL CANCER Jin C. Kim, MD, Kyung H. Kim, MD, Sung S. Yang, MD, Jae Y. Kwack, MD, Tae Y. Chang, MD, Seok B. Lim, MD, Department of
Surgery, University of Ulsan College of Medicine and Asan Medical Center, Seoul 138-736, Korea
S022: ROBOTIC COLORECTAL PROCEDURES: OUR EXPERIENCE G. Spinoglio, MD, R. Quarati, MD, F. Priora, MD, LM Lenti, PHD, F. Ravazzoni,
PHD, V. Maglione, MD, Division of Oncologic General Surgery, ASO “SS Antonio e Biagio e Cesare Arrigo”, Alessandria , Italy.
S023: TELELAP ALF-X- THE FUTURE OF ABDOMINAL SURGERY (BACK TO THE FINGERTIPS) Michael Stark, MD, Emilio Morales, SOFAR SpA,
The New European Surgical Academy; Telelap ALF-X Surgical Robotics Department
S055: ROBOT AND LAPAROSCOPIC ASSISTED GASTRECTOMY: A COMPARISON OF SURGICAL OUTCOMES Byunghee Kang MD, Junyoung Kim
MD, Sanguk Han MD, Department of Surgery, Ajou University,School of Medicine, Korea

SS03: Urology (2:00pm-3:00pm) Thalia 4


Moderators: Jacques Hubert, MD & Vassilis Poulakis, MD, PhD, FEBU
S024: SURGICAL, ONCOLOGIC AND FUNCTIONAL OUTCOMES IN PATIENTS WITH A GLEASON SCORE 8 OR HIGHER UNDERGOING
ROBOTIC-ASSISTED RADICAL PROSTATECTOMY Apostolos P. Labanaris, MD, PhD, Vahudin Zugor, MD, PhD, Jorn H. Witt, MD, PhD, Department
of Urology and Pediatric Urology - Prostate Center Northwest, St. Antonius Medical Center, Gronau, Germany
S025: ROBOTIC-ASSISTED LAPAROSCOPIC LIVING DONOR NEPHRECTOMIES: EXPERIENCE IN 100 CASES J. Hubert, MD, M. Ladriere, MD
PhD, C. Waked, MD, PhD, G. Chopin, MD, P. Eschwege, MD, PhD, P. Eschwege, MD, PhD, L. Frimat, MD, PhD, M. Kessler, MD, Dept. of Urology and
Nephrology, CHU Nancy-Brabois, allée du Morvan, 54511 Vandœuvre les Nancy, France
www.mirasurgery.org 9
SCIENTIFIC PROGRAM
S026: ROBOT-ASSISTED PARTIAL NEPHRECTOMY (RAPN). EXPERIENCE IN 60 CASES E. Barbier, PE Theveniaud, N. Hubert, MD, P. Eschwege,
MD, PhD, J. Hubert, MD, PhD, Urology Dept, CHU de Nancy-Brabois. Allée du Morvan, 54511 Vandoeuvre-Les-Nancy, France
S027: ROBOTIC ASSISTED LAPAROSCOPIC TRANSPERITONEAL PYELOPLASTY: 10 YEARS EXPERIENCE, 100 CASES J. Hubert, MD, M. Chammas,
MD, C. Egrot, MD, N. Hubert, MD, P. Eschwege, MD, PhD, J. Hubert, Department of Urology, CHU Nancy-Brabois 54511 Vandœuvre les Nancy, France
S028: ROBOTIC PROSTATECTOMY. FEASIBLE AND SAFE IN PATIENTS WITH PREVIOUS ABDOMINAL SURGERY Apostolos P. Labanaris, MD,
PhD, Vahudin Zugor, MD, PhD, Jorn H. Witt, MD, PhD, Department of Urology and Pediatric Urology, Prostate Center Northwest, St. Antonius Medical
Center, Gronau, Germany
S029: KEY AREAS IN THE LEARNING CURVE FOR ROBOTIC UROLOGICAL SURGERY: A SPANISH MULTICENTRE SURVEY Jesus Moreno Sierra,
MD, PhD, Elena Ortiz Oshiro, MD, PhD, Isabel Galante Romo, PhD, Jose Luis Senovilla, PhD, Ivan Mansilla Garcia, Maria Escudero Romo, Angel Silmi
Moyano, MD, PhD, Hospital Clinico San Carlos - Universidad Complutense de Madrid

SS04: Cardio-Thoracic (3:00pm-4:00pm) Thalia 4


Moderators: Aristotelis Panos, MD, PhD, FECTS & V. Tomulescu
S030: ROBOTIC MITRAL VALVE REPLACEMENT Changqing Gao, MD, PLA General Hospital
S031: MID-TERM FOLLOW UP AFTER ROBOTICALLY ASSISTED TOTALLY ENDOSCOPIC REPAIR OF INTRAATRIAL COMMUNICATIONS
Nikolaos Bonaros, Stepan Cerny, Felix Weidinger, Christoph Steger, Martin Michel, Silvana Mueller, Thomas Bartel, Johannes Bonatti, Thomas Schachner,
Department iof Cardiac Surgery, Innsbruck Medical University
S032: ROBOTIC TOTALLY ENDOSCOPIC CORONARY ARTERY BYPASS GRAFTING ON THE ARRESTED HEART – TWO CENTERS’
EXPERIENCE WITH 305 CASES Eric J. Lehr, MD, PhD, Thomas Schachner, MD, Nikolaos Bonaros, MD, Dominik Wiedemann, MD, Felix Weidinger,
MD, David Zimrin, MD, Bartley Griffith, MD, Johannes Bonatti, MD, University of Maryland School of Medicine, Medizinische Universität Innsbruck
S033: SEQUENTIAL CORONARY BYPASS GRAFTS FOR ROBOTICALLY ASSISTED TOTALLY ENDOSCOPIC SURGICAL REVASCULARIZATION
OF MULTIVESSEL CORONARY ARTERY DISEASE Eric J. Lehr, MD, PhD, Thomas Schachner, MD, Nikolaos Bonaros, MD, Dominik Wiedemann, MD,
Felix Weidinger, MD, Andreas R de Biasi, BS, Alina Grigore, MD, Mark Vesely, MD, Griffith Bartley, MD, Johannes Bonatti, MD, University of Maryland
School of Medicine, Medizinische Universität Innsbruck
S034: ROBOTIC THORACOSCOPIC FIRST RIB RESECTION - PRESENTATION OF A SERIES OF PATIENTS Farid Gharagozloo, Marc Margolis, MD, Eric
Strother, CSA, Barbara Tempesta, CRNP, Washington Institute Of Thoracic And Cardiovascular Surgery; The George Washington University Medical Center
S035: ROBOTIC CARDIAC SURGERY IN GREECE Aristotelis Panos, PhD, FECTS, FMH, Fotis Milas, MD, Sylvio Vlad, MD, 3rd Clinic for Cardiac
Surgery, Hygeia Hospital, Athens, Greece. La Tour Hospital, Geneva, Switzerland

4:00pm-4:30pm Coffee & Tea Break Terpsichore D

4:30pm-5:30pm CONCURRENT VIDEO SESSIONS


SS05: General Surgery Terpsichore ABC
Moderators: Fabrizio Luca, MD & Harilaos Pappis, MD, PhD, FACS
V001: ROBOTIC-ASSISTED RESECTION OF ESOPHAGEAL LEIOMYOMA Koji Park, MD, Syed Razi, MD, Jordan Sasson, MD, Cliff P. Connery, MD,
George J. Todd, MD, Scott J. Belsley, MD, Faiz Y. Bhora, MD, St. Luke’s-Roosevelt Hospital Center
V002: ROBOTIC SINGLE PORT RIGHT HEMICOLECTOMY IN AN OBESE PATIENT Vincent Obias, MD, Rami Makhoul, MD, Sam Damle, MD, Grace
Montenegro, MD, George Washington University
V003: ROBOT-ASSISTED THORACOSCOPIC ESOPHAGECTOMY AND LYMPHADENECTOMY Roy Verhage, MD, PC van der Sluis, MD, R van
Hillegersberg, MD, PhD, University Medical Center Utrecht, the Netherlands
V004: ROBOTICS MAY SAVE THE DAY WITH GANGRENOUS CHOLECYSTITIS: A NOT SO USELESS OPERATION AFTER ALL Konstantinos M.
Konstantinidis, MD, PhD, FACS, Savas C. Hiridis, Periklis S. Chrysocheris, Michael K. Georgiou, MD, Athens Medical Center
V005: ROBOTIC DISTAL PANCREATECTOMY: OUR TECHNIQUE Konstantinos M. Konstantinidis, MD, PhD, FACS, Savas C. Hiridis, MD, MSc,
Michael K. Georgiou, Perikles S. Chrysocheris, MD, aFACS, Athens Medical Center
V006 KIDS SAY THE DARNDEST THINGS...AND WHAT THEY EAT IS PRETTY WEIRD TOO John J. Meehan, Seattle Children’s Hospital, University
of Washington

SS06: Gynecology Thalia 3


Moderators: Vasiliki Chatzirafail, MD & Grigor Gorchev, MD, PhD, DSc
V007: ROBOTIC TRACHELECTOMY Vasilis Kapetanakis, MD, Paul M. Magtibay, MD, Mayo Clinic, AZ
V008: A PECULIAR VASCULAR INJURY IN ROBOTIC HYSTERECTOMY Rhoda Raji, MD, Karim ElSahwi, MD, Masoud Azodi, MD, Yale-New Haven Hospital
V009: ROBOTIC HYSTERECTOMY FOR STAGE IV ENDOMETRIOSIS Dan-Arin Silasi, MD, Taryn Gallo, MD, Yale New Haven Health / Bridgeport Hospital
V010: ROBOTIC RADICAL HYSTERECTOMY FOR VAGINAL SARCOMA Eugene P. Toy, MD, Julietta Fiscella, MD, University of Rochester
V011: ROBOTIC HYSTERECTOMY: APPROACH TO THE BULKY FIBROID UTERUS Mona Orady, MD, Division of Minimally Invasive Gynecology and
Robotic Surgery, Department of Obstetrics, Gynecology, and Women’s Health, Henry Ford Health System, Detroit, MI, USA
V012: ROBOTIC APPENDECTOMY DURING GYNECOLOGIC SURGERY: 3 DIFFERENT TECHNIQUES Taryn N. Gallo, MD, Dan-Arin Silasi, MD,
Masoud Azodi, MD, Yale New Haven Health / Bridgeport Hospital

SS07: Urology/Thoracic/Pediatric/Miscellaneous Thalia 4


Moderators: Nikolaos P. Pardalidis, MD, John Meehan, MD
V013: ROBOTIC RADICAL PROSTATECTOMY IN GREECE:5-YEAR EXPERIENCE Nick Pardalidis, Nick Andriopoulos, Aggelos Karamanis, Niki
Giannakou, Eleni Kosmaoglou, Athens Medical Centre, Marousi, Greece
V014: ROBOTIC-ASSISTED INSERTION OF AN ARTIFICIAL URINARY SPHINCTER AFTER PELVIC TRAUMA AND URETHRAL DISRUPTION
Jonathan J. Melquist, MD, Ruth Ann Miles, MD, Zelik Frischer, MD, Rahuldev Bhalla, MD, Stony Brook University Medical Center
V015: SEQUENTIAL PHOTOSELECTIVE VAPORIZATION OF THE PROSTATE AND ROBOT-ASSISTED LAPAROSCOPIC BLADDER
DIVERTICULECTOMY Nick Pardalidis, Nick Andriopoulos, Aggelos Karamanis, Eleni Kosmaoglou, Athens Medical Centre
V016: ROBOTIC ASSISTED ANTERIOR EXENTERATION FOR URETHRAL CANCER Rhoda Raji, MD, Karim Elsahwi, MD, Masoud Azodi,
Department of Obstetrics, Gynecology and Reproductive Sciences, Yale-New Haven Hospital, New Haven, CT, 06520

10 6 TH ANNUAL MIRA CONGRESS May 11-13, 2011


V017: ROBOT-ASSISTED LAPAROSCOPIC RADICAL CYSTOPROSTATECTOMY: TOTALLY INTRACORPOREAL STUDER NEOBLADDER Nick
Pardalidis, Nick Andriopoulos, Niki Giannakou, Evagelia Karagianni, Eleni Kosmaoglou, Athens Medical Center, Maroussi, Athens, Greece
V018: ROBOTIC THYMECTOMY IN A CHILD WITH MYESTHENIA GRAVIS Jacob Stephenson, MD, John J. Meehan, MD, FACS, Daniel Ledbetter,
MD, Seattle Children’s Hospital
V019: ROBOTIC MICROSURGICAL NERVE GRAFTING FOR SYMPATHECTOMY REVERSAL: TECHNIQUE AND FEASIBILITY FOR FIRST
HUMAN CASE M Jawad Latif, MD, Koji Park, MD, Syed S. Razi, MD, Faiz Bhora, MD, George Todd, MD, Noel Perin, MD, Cliff Connery, MD, Scott J.
Belsley, MD, St. Luke’s Roosevelt Hospital Center, Columbia University
V020: ROBOTIC-ASSISTED THORACOSCOPIC REPAIR OF A DIAPHRAGMATIC HERNIA WITH LIVER HERNIATION AND ENDOMETRIOSIS
CAUSING RECURRENT CATAMENIAL PNEUMOTHORAX Gary S. Schwartz, MD, Koji Park, MD, Syed Razi, MD, Scott J. Belsley, MD, Faiz Y Bhora,
MD, Cliff P Connery, MD, St. Luke’s-Roosevelt Hospital Center

5:30pm Keynote Lecture: Intuitive Surgical and the Future of Robotic Surgery Terpsichore ABC
Ryan Rhodes, Vice-President, Clinical Marketing, Intuitive Surgical, Inc.
Introduction by: Konstantinos Konstantinidis, MD
6:00pm Grand Opening Ceremony Bishop/Terpsichore ABC
Welcome message from governmental and academic authorities.
8:30pm Gala Dinner: Dreams Asteras Seaside
Come join your colleagues and friends for an evening of dinner and music at the lovely Dreams Nea Asteria Glyfadas. Located
at the beach, Dreams Nea Asteria Glyfadas offers a view of the endless blue Argosaronicos Gulf and will provide an enchanting
atmosphere for this year’s MIRA Gala Event. Attire: Casual, but bring a coat as we will be near the water and it could get chilly!
*Shuttles will depart at 8:00pm from the lobby of the Hilton Athens and be available at 10:00pm to bring attendees back to the Hilton.

FRIDAY, MAY 13, 2011


7:30am-8:00am Coffee & Tea Break
8:00am MIRA Business Meeting (All Members Welcome) Terpsichore ABC
8:30am-10:00am Robotics in Space
Moderators: Mehran Anvari, Chair of Minimally Invasive Surgery & Surgical Innovation,
McMaster University, Canada, & Richard Satava, MD
1. Scope of Robotics in Space Program – NASA/CSA Representative TBA
2. Design and capabilities of space Robotic Systems – John Lymer, Chief Engineer, Space Robotic Program, MDA
3. Transition from Space to Medical Robotics – Mehran Anvari, Chief Scientist, NASA NEEMO Missions 7 & 9
10:00am-10:15am Coffee & Tea Break Terpsichore D
10:15am-11:15am Single Incision Symposium Terpsichore ABC
Moderators: Giuseppe Spinoglio, MD & Konstantinos Konstantinidis, MD
10:15am-10:30am Introduction: Intuitive Engineer: Da Vinci Single Incision Concept – Ryan Rhodes, Vice President, Clinical Marketing, Intuitive Surgical, Inc.
10:30am-10:45am The Greek Experience – Konstantinos Konstantinidis, MD
10:45am-11:00am The Swiss Experience – Monika Hagen, MD
11:00am-11:15am The Italian Experience – Giuseppe Spinoglio, MD
11:15am-1:35pm Advances in Clinical Robotics: The Year 2010-2011 Part II Terpsichore ABC
Moderators: Ivo Broeders, MD & Piero Giulanotti, MD
11:15am-11:35am Liver and Pancreas – Piero Guilianotti, MD, FACS
11:35am-11:55am Cardiac Surgery – Johannes Bonatti, MD
11:55am-12:15pm Lung and Esophagus – Farid Gharagoozlo, MD
12:15pm-12:35pm Upper GI – Georges Lawsons, MD
12:35pm-12:55pm Robotic Surgery in Romania – Irinel Popescu, MD
12:55pm-1:25pm Improving Outcomes for 6 Million Patients: OR Ready/The Information You Need When and Where You
Need It - SLS Scholarly Search for Minimally Invasive Robotic Surgery – Paul Wetter, MD
1:25pm-1:35pm Q&A with Panelists
1:35 pm Lunch on own/Exhibits & Posters Opens
2:30pm-3:30pm CONCURRENT SESSIONS
SS08: Gynecology Terpsichore ABC
Moderators: Georgios E. Hilaris, MD, FACOG & John S Missanelli, DO
S036: SENTINEL LYMPH NODE MAPPING IN PATIENTS WITH ENDOMETRIAL CANCER UNDERGOING ROBOTICALLY ASSISTED OR
STANDARD LAPAROSCOPIC PROCEDURES Mario M. Leitao, MD, Fady Khoury-Collado, MD, Ginger J. Gardner, MD, Elizabeth Jewell, MD, Carol L.
Brown, Yukio Sonoda, MD, Douglas A. Levine, MD, Richard R. Barakat, MD, Nadeem R. Abu-Rustum, MD, Memorial Sloan-Kettering Cancer Center

www.mirasurgery.org 11
SCIENTIFIC PROGRAM
S037: A COMPARISON OF PERIOPERATIVE OUTCOMES BETWEEN ROBOTIC AND OPEN HYSTERECTOMY FOR VERY ENLARGED UTERI
Fiona Lindo, MD, Taryn Gallo, MD, Masoud Azodi, MD, Dan-Arin Silasi, MD, Yale New Haven Health / Bridgeport Hospital
S038: LEARNING CURVE FOR ROBOTIC HYSTERECTOMY: THE HENRY FORD EXPERIENCE Mona E. Orady, MD, Department of Obstetrics,
Gynecology, and Women’s Health, Henry Ford Health System, Detroit, Michigan.
S039: SAFETY AND EFFICACY OF ROBOTIC MYOMECTOMY Vasiliki Chatzirafail, MD, Michael Litos, MD, PhD, MRCOG, Theodoros Mitsis, MD,
Nikolaos Bardis, MD, Aristidis Bakas, MD, Eyroclinic,Athens, Greece
S040: LAPAROSCOPIC VS ROBOTIC FIBROID RESECTION: EXPERIENCE 2008-2010 Konstantinos P. Mirillas, MD, Konstantinos P. Mirillas, MD, Petros C.
Hiridis, MD, Dimitris Bisbikis, MD, Savas C. Hiridis, MD, MSc, Perikles S. Chrysocheris, MD, Konstantinos M Konstantinidis, MD, PhD, FACS, Athens Medical Center

SS09: Pediatric Surgery and TORS Thalia 3


Moderator: Se-Heon Kim, MD & Georges Lawson, MD
S041: USE OF ROBOT IN HIGH ANORECTAL MALFORMATION Abdulrahman Albassam, MD, Abdulmonem Gado, MD, Mohammed Mallick, MD,
Division of Pediatric Surgery, Department of Surgery, King Khalid University Hospital,
S042: FEASIBILITY AND ONCOLOGIC SAFETY OF TRANSORAL ROBOTIC HYPOPHARYNGECTOMY Se-Heon Kim, MD PhD, Young Min Park,
MD, Armando De Virgilio, MD, Yonsei University College of Medicine
S043: IS UKA MORE ACCURATE WITH ROBOTIC ASSISTANCE? Nicholas J. Dunbar, MS, Andrew D. Pearle, MD, Eduardo M. Suero, MD, Sharon
Horowitz, BS, Michael A. Conditt, PhD, Scott A. Banks, PhD, University of Florida, Hospital for Special Surgery, MAKO Surgical Corp

SS10: Novel Applications – Simulation, Research, & Miscellaneous Thalia 4


Moderators: Nikos Aspragathos & Mehran Anvari, MD
S044: VIRTUAL REALITY ROBOTIC SURGERY SIMULATOR: MIMIC® DV-TRAINER, A TOOL FOR CERTIFICATION? C. Perrenot, MD, M. Perez,
MD, N. Tran, MD, J. P. Jehl, J. Felblinger, MD, PhD, J. Hubert, MD, Urology Dept & IADI, CHU Nancy-Brabois. Allée du Morvan, 54511 Vandoeuvre-les-
Nancy, France
S045: DEVELOPMENT OF A SEMI-AUTOMATED ROBOT-ASSISTED FLEXIBLE ENDOSCOPE N. van der Stap, BS, R. Reilink, MS, I.A.M.J. Broeders,
Prof. Dr., S. Misra, Dr., S. Stramigioli, Prof. Dr. IR, MIRA, University of Twente; Meander Medical Center
S046: ADVANCED ROBOTIC MULTI-DISPLAY EDUCATIONAL SYSTEM (ARMES), AN INNOVATIVE REAL-TIME AUDIOVISUAL MENTOR
DURING COMPLEX ROBOTIC SURGERY Yanghee Woo, MD, Kazutaka Obama, MD PhD, Tae-il Son, MD, Hyung Il Kim, MD, Woo Jin Hyung, MD Phd,
Department of Surgery, Robot and Minimally Invasive Surgery Center at Yonsei University College of Medicine, Seoul, Korea
S047: DEVELOPMENT OF A USER INTERFACE FOR COLONOSCOPE CONTROL N. Kuperij, BSc, R. Reilink, MSc, IAMJ Broeders, Prof. Dr., MP
Schwartz, Dr., S. Stramigioli, Prof., University of Twente, Department of Technical Medicine, University of Twente, Enschede, The Netherlands
S048: ROBIN HEART - FROM VIRTUAL TO REAL SURGEON TOOLS Zbigniew Nawrat, MD, Pawel Kostka, PhD, Foudation of Cardiac Suregry Development

3:30pm-3:45pm Coffee & Tea Break Terpsichore D

3:45pm-5:00pm SS11: Plenary Best Abstract and Video Session Terpsichore ABC
Moderators: Ivo Broeders, MD & Mehran Anvari, MD
S049: ROBOT ASSISTED- VS. CONVENTIONAL LAPAROSCOPY: A STUDY OF THE IMPACT OF HYSTERECTOMY TYPE AND UTERINE SIZE
Gunjal Garg, Deslyn Hobson, Saima Ghazal, Ylbe Franco, Sonia Kim, S. Gene L. McNeeley, David C. Kmak, Awoniyi Awonuga, Susan L. Hendrix, Wayne
State University/ Detroit Medical center
S050: ROBOTIC-ASSISTED SALVAGE PROSTATECTOMY. SURGICAL, ONCOLOGIC AND FUNCTIONAL OUTCOMES Apostolos P. Labanaris, MD,
PhD, Vahudin Zugor, MD, PhD, Jorn H. Witt, MD, PhD, Department of Urology and Pediatric Urology – Prostate Center Northwest, St. Antonius Medical
Center, Gronau, Germany
S051: ONCOLOGICAL OUTCOMES OF ROBOTIC GASTRECTOMY FOR GASTRIC CANCER COMPARED TO LAPAROSCOPIC GASTRECTOMY
Kazutaka Obama, MD, Woo Jin Hyung, MD, PhD, Yanghee Woo, MD, Hyoung-Il Kim, Sung Hoon Noh, MD, PhD, Yonsei University College of Medicine
S052: MULTIDIMENSIONAL ANALYSES OF THE LEARNING CURVE OF ROBOTIC GASTRECTOMY FOR GASTRIC CANCER: A COMPARISON
WITH LAPAROSCOPIC GASTRECTOMY Hyoung-Il Kim, MD, Woo Jin Hyung, MD, Yanghee Woo, MD, Kazutaka Obama, MD, Sung Hoon Noh, MD,
Department of Surgery, Institute of Gastroenterology, and Cancer Metastasis Research Center Yonsei University College of Medicine, Seoul, Korea
S053: COMPARISON OF ROBOTICALLY ASSISTED AND STANDARD LAPAROSCOPIC PROCEDURES IN PATIENTS WITH ENDOMETRIAL
CANCER Mario M. Leitao, MD, Ginger J. Gardner, MD, Gabriel Briscoe, Kevin Santos, Elizabeth Jewell, MD, Nadeem R. Abu-Rustum, MD, Carol L.
Brown, MD, Dennis S. Chi, MD, Yukio Sonoda, MD, Richard R. Barakat, MD, Memorial Sloan-Kettering Cancer Center
V021: NOT A MATTER OF SIZE Vasiliki Chatzirafail, MD, Michael Litos, MD, PhD, MRCOG, Antigoni Issari, MD, Euroclinic, Athens, Greece
V022: ROBOTIC SURGERY FOR ENDOMETRIOSIS UTILIZING THE 5MM DAVINCI SYSTEM Taryn n Gallo, MD, Masoud Azodi, MD, Yale New
Haven Health / Bridgeport Hospital
S054: MULTICENTER STUDY OF ROBOTIC VERSUS ENDOSCOPIC THYROIDECTOMY FOR THYROID CANCERS: POSTOPERATIVE
OUTCOMES AND SURGEON ERGONOMIC CONSIDERATIONS Hee-Lee-Nah Suh, MD, Jandee Lee, MD, Sang Wook Kang, MD, Jeoung Ju Jung, MD,
Un Chung Choi, MD, Jong Ho Yun, MD, Woong Youn Chung, MD PhD, Ajou University School of Medicine1, Yonsei University College of Medicine2,Won-
Kwang University College of Medicine3, Ulsan University School of Medicine

5:00pm-5:15pm Coffee & Tea Break Terpsichore D

5:15pm-6:15pm The Robotic Olympic Contest Terpsichore ABC


Come Watch as the Top Eight Contestants battle it out for the Gold, Silver and Bronze Medals of the Robotic Olympics!
Moderators: Paul Alan Wetter, MD, Jacques Hubert, MD, Monika.Hagen, MD & Savas Hiridis, MD

6:15pm-7:00pm Robotics in Surgery: Where Are We Heading? – Richard Satava, MD, FACS Terpsichore ABC
Moderators: Ivo Broeders, MD & Konstantinos Konstantinidis, MD

7:00pm Closing Lectures Terpsichore ABC


Jacques Hubert, MD (Past President), Johannes Bonnati, MD (President) and Closing Remarks from Congress President
12 6 TH ANNUAL MIRA CONGRESS May 11-13, 2011
Oral Abstracts
S001: ROBOTIC VERSUS ENDOSCOPIC THYROIDECTOMY FOR S003: THE USEFULNESS OF ROBOTIC THYROIDECTOMY FOR THE
THYROID CANCERS: A MULTI-INSTITUTIONAL ANALYSIS OF EARLY MANAGEMENT OF BENIGN THYROID DISEASE George Giannopoulos, MD,
SURGICAL OUTCOMES Jandee Lee, MD PhD, Jong Ho Yun, MD, Kee Hyun Jae Hyun Park, MD, Jong Ju Jeong, MD, Sang-Wook Kang, MD, Woong Youn
Nam, MD, Woong Youn Chung, MD PhD Yonsei University College of Medicine Chung, MD Department of Surgery, Yonsei University College of Medicine
Objectives: Robotic thyroidectomy has several advantages over conventional Introduction: Thyroid surgery for benign diseases involves mainly young women,
endoscopic thyroid surgery, including a three-dimensional surgical view, and so cosmetic considerations have motivated the development of various “no
fine and free movement of the robotic arm in the surgical fields. However, scar to the neck” operations. However, endoscopic techniques are often very
few studies have compared the robotic and pure endoscopic thyroidectomy strenuous and perhaps, discouraging to adopt. Recent incorporation of robotic
techniques in terms of postoperative outcomes. The aim of this multicenter technology in thyroid surgery, proposes a feasible, safe, extra-cervical approach,
study was to confirm the merits of robotic thyroidectomy by comparing alleviating most of the technical difficulties of endoscopy. In these terms,
endoscopic thyroidectomy in patients with thyroid carcinomas. endoscopic skills are possibly not a prerequisite. Herein we present our series of
benign thyroid diseases that underwent robot-assisted thyroidectomy, reviewing
Materials & Methods: Between November 2001 and June 2010, a total of 2,612
patients with thyroid carcinomas underwent at three centers by four surgeons. the essential steps in proper patient selection.
Of these patients, 1,769 patients underwent robotic thyroidectomy (robotic Methods & Procedures: Thirty nine patients were operated in a single institution,
group), and 843 patients a conventional endoscopic thyroidectomy (endoscopic from November 2007 to October 2010. Indications for surgery were follicular/
group). These two groups were retrospectively compared with respect to patient Hürthle cell lesions smaller than 5 cm, nodules with indefinite/suspicious
characteristics, operative outcomes, complications, and pathologic results. fine-needle aspiration findings and Graves disease. All patients underwent
robot-assisted thyroidectomy using a gasless transaxillary approach, with
Results: The patient demographics were similar in both groups. A total of 856
no conversion to open surgery. The characteristics of the patients and the
(32.8%) total thyroidectomy and 1274 (67.2%) less-than total thyroidectomy
procedure were evaluated retrospectively.
was carried out. Total thyroidectomy was performed more frequently in the
robotic group (p=0.004). The groups were comparable in tumor size, pathology, Results: From a total of 39 patients, 34 were women and 5 men. Mean age was
multiplicity, and bilaterality. However, tumor stage in the robotic group was 38 ±10.9 years. The most common pathology was adenomatous hyperplasia
more advanced than in the endoscopic group (p=0.002). Statistically significant (21 lesions), followed by follicular adenoma (9 lesions). Hashimoto thyroiditis
differences were noted in favor of robotic vs. endoscopic total thyroidectomy with was found in 4 cases and Graves’ disease was the indication in 5 cases. Mean
regard to operative times (p<0.001). The total number of retrieved central lymph nodular lesion size was 1.8 ±1.1 cm; no lesion proved to be malignant in final
nodes was greater in the robotic group (p=0.012). The two groups showed no pathology. Twenty three patients underwent lobectomy, 11 subtotal and 5
significant differences in terms of intra-operative and postoperative complications. total thyroidectomy. Mean operative time was 131.6 ±39.1 minutes and mean
postoperative hospital stay was 3 ±0.3 days. No intra-operative complications
Conclusion: Robotic thyroidectomy using a gasless transaxillary approach was a
occurred; postoperative complications were 1 transient hoarseness, 1 transient
feasible, safe procedure and provided good outcomes for differentiated thyroid
hypocalcemia and 1 permanent unilateral RLN injury.
carcinoma patients. The present study also showed that robot technology
overcame some technical limitations associated with conventional endoscopic Conclusion: Robotic thyroidectomy with gasless transaxillary approach, although
procedures in terms of operation time, and lymph node retrieval. recent and sophisticated, has already been applied in over 1000 thyroid cancer
patients in Korea and several teams in USA and Europe have demonstrated
S002: INITIAL RESULTS OF ROBOTIC -ASSISTED THYROIDECTOMY their initial experience. Nevertheless, proper patient selection is imperative,
THROUGH A GASLESS TRANSAXILLARY APPROACH Andreas and patients with a follicular lesion concerned about a neck scar, seem to be the
Kiriakopoulos, MD, Efthimios Poulios, MD, Dimitrios Linos, MD, 1st Surgical best candidates. Small nodules suspicious for papillary cancer, are also a rational
Clinic, Department of Surgery, Hygeia Hospital, Athens, Greece choice, as the operation is not extended considerably. On the contrary, Graves’
Aim: Patients that form keloid and need thyroidectomy do benefit from a disease should be reserved unless significant experience has gained.
scarless neck approach via the axilla using the robotically assisted Chung
S004: A SURGICAL COMPLETENESS OF ROBOTIC THYROIDECTOMY:
technique. We present our initial experience with this technique.
A PROSPECTIVE COMPARISON OF THE OPEN CONVENTIONAL
Patients & Methods: Eight patients (6 females and 2 males, mean age 38.8 yrs, THYROIDECTOMY VERSUS THE ROBOTIC THYROIDECTOMY 1Jae
range: 30-56) having favorable body habitus (mean BMI 23.4, range: 18-30) Hyun Park, 2Jong Ho Yoon, 3Chi Young Lim, 1Kyu Hyung Kim, 1Sohee Lee,
underwent robotic-assisted thyroidectomy through a gasless transaxillary 1
Haeng Rang Ryu, 1Sang-Wook Kang, 1Jong Ju Jeong, 1Kee-Hyun Nam, 1Woong
approach. All procedures were performed with the da Vinci S surgical robot Youn Chung, 1Cheong Soo Park 1) Yonsei University College of Medicine, 2)
system using four robotic arms. Skin flap dissection, robot docking and Asan Medical Center, University of Ulsan College of Medicine, 3) National
gasless robotic thyroidectomy comprise the operative steps involved. Patient’s Health Insurance Corporation Ilsan Hospital
demographic data, operative time, complications, conversions, hospital stay
and cosmetic results are presented. Background: With the application of da Vinci robotic system to thyroidectomy
fields, surgeons can perform a precise and accurate operation with improved
Results: Three lobectomies, two near-totals, two totals and one total cosmesis. The aim of this study is to compare the surgical completeness of
thyroidectomy with lateral lymph node dissection have been performed. two groups who underwent conventional open thyroidectomy versus robotic
Mean diameter of the largest nodule in this series was 26.5 mm (range: 18- thyroidectomy in papillary thyroid carcinoma patients.
60). Mean total operative time was 211 min (range: 165-250) consisting of
a mean 32 min (range: 20-40) flap dissection time, a mean 13 min (range: Materials & Method: From March to November 2009, a total of 115 patients
10-20) docking time and a 166 min (range: 130-210) console time. We had with papillary thyroid carcinoma who underwent total thyroidectomy
no conversions and a drain was left in place in all patients that was removed and postoperative radioactive iodine(RAI) ablation therapy(30mCi) at
2.8 days later. We had one temporary recurrent laryngeal nerve paralysis. Yonsei University Health System were enrolled. Of these, 58 patients were
Two patients exhibited transient symptomatic hypocalcemia. Three patients conventional open thyroidectomy group(OG) and 57 patients were robotic
complained of hypoesthesia/disturbed sensation in the flap dissection area. thyroidectomy group(RG). These two groups were prospectively compared
Mean hospital stay was 1.5 days (range: 1-3). Postoperative pain was minimal with respect to clinicopathological characteristics, surgical outcomes and
and cosmetic results excellent. surgical completeness.

Conclusions: Our preliminary results show that robotic-assisted thyroidectomy Results: Mean age was significantly younger in RG. Mean tumor sizes were larger
through a transaxillary approach is safe and feasible. Robotic application is in RG, but the incidence of capsular invasion, multifocality and bilaterality
associated with excellent view of the critical neck anatomy that allows precise showed no significant differences between two groups. Tumor and nodal status
tissue handling and dissection. However, more studies are needed to define showed no significant differences, but advanced stage is more frequent in OG.
its role in modern thyroid surgery and to convince both patients and medical In terms of surgical outcomes, there were no significant differences in numbers
world about its actual advantages. of retrieved central nodes, lengths of postoperative hospital stay, and incidences
of postoperative complications. In terms of surgical completeness, stimulated

www.mirasurgery.org 13
Oral Abstracts
serum thyroglobulin(Tg) level and relative 131 iodine uptake of operation Conclusion: Robotic splenectomy will probably not replace the laparoscopic
bed (thyroid uptake/whole body upatke and thyroid uptake/brain uptake) splenectomy for the most common indications like ITP, hemolytic anemia. It
was significantly higher in RG. However, serum Tg level which was measured may be a very useful surgical tool in difficult splenectomy and allows resection
six months after RAI therapy under TSH suppression showed no significant of splenic cysts with a margin of healthy tissue without risk of bleeding or
differences between two groups. recurrence. Robotic surgery of splenic cysts seems to offer safety and all benefits
of minimally invasive surgery, preserves the immune function of the spleen and
Conclusion: Robotic thyroidectomy showed a comparable surgical completeness
allows the surgeon to conserve as much of splenic parenchyma as possible.
with conventional open procedure in papillary thyroid carcinoma patients who
were managed with RAI ablation therapy after total thyroidectomy. S007: ROBOTIC SINGLE PORT COLON RESECTIONS: INITIAL
EXPERIENCE Rami Makhoul, MD, Grace Montenegro, MD, Vincent Obias,
S005: A COMPARATIVE STUDY OF ROBOTIC VERSUS CONVENTIONAL
MD, George Washington University
OPEN MODIFIED RADICAL NECK DISSECTION FOR THE PAPILLARY
THYROID CARCINOMA WITH LATERAL NECK NODE METASTASIS Introduction: The application of laparoscopic (Lap) single site surgery is increasing
Sang-Wook Kang, MD, Kyu Hyung Kim, MD, Jae Hyun Park, MD, So Hee in the field of minimally invasive surgery and recently has become more popular
Lee, MD, Woong Youn Chung, MD Department of Surgery, Yonsei University in colon and rectal surgery. In addition to the possibility of decreasing post-
College of Medicine operative pain, it improves cosmesis and minimizes tissue trauma. However,
instrument conflict, poor ergonomics, and increased technical difficulty has
Purpose: Since the introduction of endoscopic technique to thyroid surgery, several
minimized its complete adaptation. We believe the Robotic (Rbt) system can
endoscopic lateral neck dissection trials have been conducted with the aim of
minimize these unique technical challenges. We would like to share our early
avoiding a long cervical scar, and the recent introduction of surgical robotic
experience, the largest in the literature to date, with robotic single incision
systems has simplified and increased the precisions of endoscopic techniques.
colectomies with regards to safety and feasibility.
The aim of this study was to evaluate and compare the early surgical outcomes
of robotic and conventional open modified radical neck dissection (MRND) for Methods: We analyzed 8 patients (pts) who underwent single incision Rbt right
papillary thyroid carcinoma (PTC) with lateral neck node metastasis (LNM). hemicolectomy between March 2010 and October 2010 by a single surgeon at
our institution. The Rbt approach using the DaVinci-S Robot and SILS access
Patients & Methods: From January 2009 to May 2010, 165 patients with PTC
device was performed on these pts. A single 4cm incision around the umbilicus
underwent bilateral total thyroidectomy with ipsilateral MRND for PTC with
was done, three robotic arms were used, and a medial to lateral approach with
LNM. Of these patients, 56 underwent a robotic procedure using a gasless,
extracorporeal resection and anastomosis was performed. At the beginning of
transaxillary approach (the robotic group; RG) and 109 a conventional open
the case, the robotic arms are crossed and in the console the hand designations
procedure (the conventional open group; OG). These two groups were
are switched so that the right hand controls what looks to be the right
retrospectively compared in terms of their clinicopathologic characteristics,
instrument (which is acutally the left crossed over) and vice versa. This improves
early surgical outcomes, and surgical completeness.
dexterity in the abdomen. Age, gender, body mass index (BMI), operative (Op)
Results: The RG was younger than the OG(35.8±9.1 vs. 46.1±13.0, P<0.0001). time, estimated blood loss (EBL), morbidity, number of lymph nodes harvested
The operative time was longer in the RG than the OG(277.4±43.2 vs. and length of hospital stay (LOS) were analyzed.
218.2±43.8min, P<0.0001). The number of retrieved lymph nodes were
Results: There were no intra-operative complications. 3 of 8 pts who
similar between the RG and OG.(37.3±12.8 vs. 39.4±14.1, P=0.359). The RG
underwent the robotic technique were converted to Lap due to air leaks
had smaller tumor size(1.14±0.59 vs. 1.49±0.80, P=0.004) and earlier stage
around the access device. There were no conversions to open. Mean Op
than the OG(stage I:IVa = 80.4%:19.6% vs. 46.3%:53.7%, P<0.0001). The
time was 203 min. Mean EBL was 125 ml and average LOS was 5.1 days.
period of hospital stay after surgery was shorter in the RG than the OG(6.0±2.5
Average number of lymph nodes harvested was 20.5. Morbidity included
vs. 8±5.2, P=0.008). Compared with the OG, the complication-rate was not
prolonged ileus and aspiration pneumonia in one pt. Two other pts separately
different. There was no abnormal uptake on RAI scans in the two groups. The
experienced a wound infection and anastomotic bleeding, which resolved with
mean level of serum Tg(TSH suppressed) were acceptable in the two groups.
conservative management.
The patients who had >1 ng/ml of serum Tg were 3 and 7 in the RG, and OG,
respectively(Tg level; 4.59±4.54 vs. 3.41±2.40). Conclusion: Robotic single incision right hemicolectomy can be successfully and
safely performed. The surgeon noted improved ergonomics and better bowel
Conclusions: Robotic MRND was found to be similar to conventional open
manipulation compared to the Lap approach. Initial Op times were quite long,
MRND in terms of early surgical outcomes and surgical completeness but to
but they are decreasing. Loss of pneumoperitoneum was the main cause of
offer an advantage of excellent cosmetic result. Based on our initial experiences,
conversion from Rbt surgery to Lap surgery, but upcoming advances in single
robotic MRND should be viewed as an acceptable alternative method in low risk
port robotic surgery should help reduce this problem. Further large scale studies
PTC patients with lateral neck node metastasis.
are needed to confirm these data.
S006: ROBOTIC SURGERY OF SPLENIC CYSTS Catalin Vasilescu, Assoc
S008: 180 GENERAL SURGERIES UNDER DA VINCI S SYSTEM IN ONE
Prof PhD, Stefan Tudor, Dana Elena Giza Fundeni Institute of Digestive Disease
INSTITUTE IN CHINA Ningxin Zhou, Junzhou Chen, Quanda Liu, Xiaodong
and Liver Transplantation, Bucharest, Romania
Zhang, Qiang Sun, Yu Xie, Qijun Xia, Zhizhong Zhang, Zhenyu Zhu Institute
Background: The authors reviewed their initial experience with robotic approach of Hepatobiliary & Gastrointestinal Diseases, PLA Second Artillery General
for splenic cysts to identify the indications, success rate, and complications Hospital
associated with this procedure.
Objectives: To summarize the clinical experience in 180 general surgeries under
Materials & Methods: 60 patients aged 6 to 76 years (average 32.6 years) da Vinci S system.
underwent robotic splenectomy between February 2008 and September 2010
Methods: From January 2009 to October 2010, 180 patients with hepato-
for different indications. Three patients with non-parasitic splenic cysts were
pancreatico-biliary (HPB) and gastrointestinal disease underwent robotic surgery
treated by robotic approach. The localization was in the upper pole in one
by using da Vinci S system. The clinical data of 180 patients were analyzed.
case, in the lower pole in one case and one case with multiple splenic cysts
and the procedures were one total splenectomy and two partial splenectomy. Results: 171 patients have undergone robotic surgery throughout. 9 patients
Four patients with splenic hydatidosis were treated by robotic approach. The have converted to hand-assisted procedure and the conversion rate was 5.0%
localization was in the upper pole in one case and voluminous cysts in the hilar (9/180). Among them, there were 63 surgeries in hepatic portal (including
region in the other three and the procedures were one hemisplenectomy and 36 in hilar cholangiocarcinoma, 10 in gallbladder carcinoma, 12 in complex
three partial splenectomies with lower pole preservation. hepatolithiasis, and 5 in latrogenic bile duct injuries); 44 surgeries in pancreas
(including 16 in pancreaticoduodenectomy, 6 in resection of pancreatic body
Results: The mean operative time was 120 min (±37 min) with a console time
and tail, 1 in medial pancreatectomy, 1 in pancreatic pseudocyst, and 20 in
of 95 min (±28 min); the mean hospital stay was 5 days (±2 days). There
palliative operations); 19 surgeries in liver; 12 surgeries in gastrointestinal;
were no conversions to open or laparoscopic surgery. No morbidity and no
and 42 in others (including lithotomy of common bile duct exploration,
mortalities occurred.
14 6 TH ANNUAL MIRA CONGRESS May 11-13, 2011
retroperitoneal lymph nodes dissection, and splenectomy and so on). There S011: PEDIATRIC ROBOTIC SURGERY: THE ULTIMATE DIVERSITY John
were 12 cases with postoperative complications and the overall complication J Meehan, MD Seattle Children’s Hospital, University of Washington
rate was 6.7% (12/180). There were 2 died cases and the mortality rate was Robotic surgery has huge potential in all forms of minimally invasive surgery.
1.1% (2/180). There were no device-related complications. Recovery was Pediatric surgery is a unique field because it combines a wide variety of acquired
accelerated and blood loss was less. problems with numerous congenital malformations. Robotic surgery is a form
Conclusion: Almost all operations in hepato-pancreatico-biliary (HPB) surgery of minimally invasive surgery which has opened new fronitiers in the surgical
could be performed successfully by employing da Vinci S system. Robotic surgery treatment of children. However, there are numerous limitations including
will improve the development of minimally invasive surgery to a large extent. equiment size, patient size, and the economics of robotics in a children’s hospital
which has limited its potential growth. We present an 8 year summary and
S009: IS THERE ANY ROLE OF ROBOT-ASSISTED SURGERY OVER review of our experience with over 300 pediatric general surgery robotic cases
LAPAROSCOPIC SURGERY FOR GASTRIC CANCER? Young-Woo Kim, and nearly 50 different types of procedures or diagnosis. The best applications
PhD, Hong Man Yoon, MD, Jun Ho Lee, PhD, Keun Won Ryu, PhD, Bang- include mediastinal mass resections, complex hepatobiliary procedures,
Ul Eom, MD, Il Ju Choi, PhD, Chan Gyoo Kim, PhD, Soo Jeong Cho, PhD, GI procedures in both the upper abdomen and also in the pelvis, and most
Jong Seok Lee, MD, Myeong-Cherl Kook, PhD, Ji Young Rhee Gastric Cancer genitourinary procedures. Fundoplications and cholecystectomies function
Branch, Research Institute and Hospital, National Cancer Center, Korea well as teaching cases for all levels of training. Procedures with less obvious
Purpose: A minimal invasive surgery has been developed, and proved to benefit include pulmonary lobectomies due to the availability of superior non-
increase short term quality of life in early gastric cancer. Robot-assisted distal robotic thermal sealing technologies as alternatives. Limitations include loss
gastrectomy(RADG) has theoretical advantages over laparoscopy-assisted of maneuverability in smaller patients below certain threshold sizes. These
distal gastrectomy(LADG) with regard to increased degrees of freedom of limitations become more signifiicant in abdominal procedures for children
instruments and enhanced dexterity through 3-dimensional view. The aim of smaller than 3 kg and thoracic procedures for children less than 4 kg.
study was to see role of RADG for gastric cancer compared LADG.
S012: ROBOT-ASSISTED TOTAL GASTRECTOMY FOR EARLY GASTRIC
Methods: We conducted single center-based case-control study. The study included CANCER COMPARING WITH LAPAROSCOPY-ASSISTED TOTAL
408 patients underwent LADG, and 115 patients underwent RADG in National GASTRECTOMY Young-Woo Kim, PhD, Hong Man Yoon, MD, Jun Ho Lee,
Cancer Center between Feb 2009 and Nov 2010. No patient in given period was PhD, Keun Won Ryu, PhD, Il Ju Choi, PhD, Chan Gyoo Kim, PhD, Soo Geong
excluded in analysis. Clinicopathologic data, operation related data, postoperative Cho, PhD, Jong Seok Lee, PhD, Myeong-Cherl Kook, PhD, Ji Young Rhee,
morbidity and pathologic data were analyzed by Student t-test and Chi-Square test. PhD, Young-iee Park, PhD Gastric Cancer Branch, Research Institute and
Results: Age of patients was 58.72+11.7 in LADG and 53.6+12.1 in Hospital, National Cancer Center,Korea
RADG(p<0.001). Postoperative hospital days was 7.9+3.6 in LADG and Purpose: In early gastric cancer, the quality of life has been important because
7.5+4.4 in RADG (p=0.391). BMI was 23.7+3.0 in LADG and 24.0+3.4 in of long term survival. Minimal invasive surgery has been developed. However,
RADG (p=0.346). Operating time was 197.1+100.0 in LADG and 240.2+44.0 laparoscopy-assisted total gastrectomy(LATG) has been still more difficult
in RADG (p<0.001). Number of dissected lymph nodes was 33.6+12.1 in for surgeons than conventional open total gastrectomy. Robot-assisted total
LADG and 35.3+12.7 in RADG (p=0.189). In 431 patients who underwent gastrectomy(RATG) has theoretical advantages, such as increased degrees of
D2 lymph node dissection, number of dissected lymph nodes in N2 area was freedom of instruments and 3-dimensional view, over LATG . The aim of this
13.0+6.3 in LADG and 14.9+7.3 in RADG. (p=0.01). Regarding postoperative study was to compare RATG with LATG in early gastric cancer in terms of
complications, there were 49 patients(12.0%) in LADG and 10 patients(8.7%) in surgical and oncologic outcomes
RADG (p=0.321).
Methods: We conducted single center-based case-control study. The study
Conclusions: RADG could have advantage over LADG in terms of more exact included 42 patients underwent LATG, and 29 patients underwent RATG at the
dissection of lymph nodes at N2 area. Prospective controlled study is needed to National Cancer Center, Korea between Feb 2009 and Nov 2010. No patient in
clarify this issue. given period was excluded in analysis. Clinicopathologic data, operation related
data, postoperative morbidity and pathologic data were analyzed by Student
S010: ROBOTIC TRANSANAL ABDOMINAL ANORECTAL RESECTION t-test and Chi-Square test.
( TATA) WITH SPHINCTER PRESERVATION FOR CANCER IN THE
DISTAL RECTUM AFTER NEOADJUVANT THERAPY G Spinoglio, MD, R Results: Age of patients was 57.1+12.2 in LATG and 54.0+12.3 in RATG
Quarati, MD, F Priora, MD, LM Lenti, PhD, F Ravazzoni, PhD, V Maglione, (p=0.293). Postoperative hospital days was 11.0+12.3 in LATG and 9.0 +3.6
MD Division of Oncologic General Surgery, ASO “SS Antonio e Biagio e Cesare in RATG (p=0.327). BMI was 23.6+3.1 in LATG and 23.1+2.7 in RATG
Arrigo”, Alessandria, Italy (p=0.485). Operating time was 211.7+58.5 in LATG and 314.6+37.0 in RATG
(p<0.001). Number of dissected lymph nodes was 41.2+14.0 in LATG and
Aim: Surgical treatment of locally advanced distal rectal cancer remains the only 42.8+11.5 in RATG(p=0.620). In 65 patients who underwent D2 lymph node
method for apotential cure. Robotic total mesorectal excision (RTME) has been dissection, number of dissected lymph nodes in N2 area was 12.1+5.5 in LATG
shown to be safe and effective. Great emphasis is placed not only on oncologic cure and 12.8+4.8 in RATG. (p=0.564). Regarding postoperative complications,
but also on maintenance of quality of life with sphincter preservation We report our there were 7(16.7%) in LATG and 5 (17.2%) in RATG (p=0.949).
initial experience with robotic radical transanal abdominal proctosigmoidectomy
with coloanal anastomosis (TATA) after neoadjuvant therapy. Conclusion: Despite of early experiences, RATG was comparable to LATG
regarding to surgical and oncologic outcomes. Prospective controlled study is
Surgical Technique & Results: Our robotic activity began in December 2005 no needed to clarify this issue.
stopped in November 2007 and started again in March 2010 using the robotic
system Da Vinci® Si HD. 129 patients underwent colorectal robotic surgery. In S013: 58 OPERATIONS ON BILIARY MALIGNANT TUMOR UNDER DA
49cases we performed a RTME and in the last 3 patients, 2 males and 1 female, we VINCI S SYSTEM Ningxin Zhou, Junzhou Chen, Quanda Liu, Xiaodong Zhang,
decided to proceed with sphincter-preserving surgery by TATA technique. All the Tao Zhang Institute of Hepatobiliary & Gastrointestinal Diseases, PLA Second
three patients were operated on 8 weeks after neoadjuvant therapy. The mean level Artillery General Hospital
of the tumor to the anorectal ring was 3.3 cm ( range, 3-5 cm). The mean tumor
Objectives: To summarize the clinical experience in 58 operations on biliary
size was 5.3 cm (range: 3-7 cm). All tumors were mobile before surgery.
malignant tumor under da Vinci S system.
Conclusions: Robotic technology is especially suitable for dissection in narrow
Methods: From January 2009 to October 2010, 58 patients (36 males, 22
spaces such as the pelvis, in which three-dimensional vision and increased
females, aged from 48-85, with the average age of 68) with biliary tract
dexterity help in the performance of TME. Benefit of TATA approach is derived
malignancy disease underwent robotic surgery by using da Vinci S system. The
from beginning the dissection transanally, that grants a maximal and precisely
clinical data of 58 patients were analyzed.
assessed distal margin to the cancer.In our experience another advantage is the
greater freedom of movement of the rectum during TME that facilitates the Results: 3 cases of intrahepatic bile duct cystadenocarcinoma received operations
dissection in the narrow pelvic cavity. of hepatectomy; 36 cases of hilar cholangiocarcinoma (62.1%, 36/58),
www.mirasurgery.org 15
Oral Abstracts
including 3 anatomical left hepatectomies, 3 operations of extrahepatic bile Results: Operation for malignant pathology was 70.6% and 78.1% for conventional
duct resection and gallbladder-bridge biliary reconstruction, 14 operations of total laparoscopic group and robot-assisted laparoscopic group, respectively. The
extrahepatic bile duct resection and biliary-enteric Roux-en-Y anastomosis, rate of anatomical resection was 52.9%, and 81.3%, respectively. Two patients
1 tumor resection and reconstruction of hilar bile duct, 5 cases of palliative (11.8%) in total laparoscopic group needed open conversion, and one patient
bilary external drainage, and 10 cases of Y-type bilary internal drainage with T (3.1%) in robotic group needed to convert to hand-assisted approach. There was
tube; 10 cases of gallbladder carcinoma (including 2 operations of gallbladder no significant difference in mean operating time (88.6 vs. 209.5 minutes), median
anf extrahepatic bile duct resection and biliary-enteric Roux-en-Y anastomosis, blood loss (65 vs. 100 ml), complication rate (23.5 vs. 9.3%), procedure related
3 cholecystectomies, 1 operation of cholecystectomy and bilary external mortality rate (0 vs. 0%) and median hospital stay (11 vs. 5 days) between the 2
drainage, 4 operations of cholecystectomy, and Y-type bilary internal drainage groups. There was no significant difference in R0 surgical margin rate (100% vs.
with T tube); 1 operation of middle common bile duct cancer (1.7%, 1/58), 92.6%) for patients with malignant disease also.
with radical resection of extrahepatic bile duct biliary-enteric Roux-en-Y Conclusion: Robot-assisted laparoscopic liver resection was feasible, and safe.
anastomosis); 8 operations of lower common bile duct cancer (13.8%, 8/58) Robot-assisted approach tended to have a lower complication rate and shorter
, including 7 cases of pancreaticoduodenectomy and 1 case of biliary-enteric hospital stay than conventional total laparoscopic approach.
Roux-en-Y anastomosis. 2 patients converted to hand-assistant procedure
and the convcersion was rate 3.4% (2/58). The complication rate was 13.8% S016: THE IMPACT OF BODY HABITUS ON SURGICAL OUTCOMES OF
(8/58), including 3 postoperative bile leakage, 1 bleeding, 2 cases of pancreatic TRANSAXILLARY SINGLE-INCISION ROBOTIC THYROIDECTOMY IN
anastomotic leakage, 1 pulmonary infection and 1 renal failure. Mortality rate PAPILLARY THYROID MICROCARCINOMA (PTMC) PATIENTS Sohee
was 3.4% (2/58) with 1 patient dead from serious lung infection and the other Lee, Haeng Rang Ryu, Jae Hyun Park, Kyu Hyung Kim, Sang-Wook Kang, Jong
dead from postoperative renal failure. Ju Jeong, Kee-Hyun Nam, Woong Youn Chung, Cheong Soo Park Department
Conclusion: Various types of operation about biliary malignant tumor can be of Surgery, Yonsei University Health System
performed robotically. Robotic techniques are particularly valuable in very Background: Robotic applications have achieved safe and meticulous
challenging hilar biliary surgeries such as bile duct exploration, reconstruction thyroidectomy with notable cosmetic and functional benefits. The aim of this
and anastomosis. Compared to laparoscope, da Vinci S System has broken the retrospective study was to document the influence of body habitus on the
limit in hepatobiliary surgeries in traditional open surgeries, especially for robotic thyroidectomy in papillary thyroid microcarcinoma (PTMC) patients.
patients with old age, jaundice and with advance disease, because they could
choose redical or palliative surgeries during the process. Methods: From July 2009 to February 2010, 352 patients underwent the robotic
thyroidectomy using a gasless, transaxillary single-incision approach in the
S014: ROBOT-ASSISTED PYLORUS PRESERVING GASTRECTOMY FOR Department of Surgery at the Yonsei University Health System, Seoul. Body
GASTRIC CANCER Dong-Seok Han, MD, Yun-Suhk Suh, MD, Seong-Ho habitus which influenced on robotic thyroidectomy were described by body mass
Kong, MD, Hyuk-Joon Lee, MD PhD, Han-Kwang Yang, MD PhD Department index (BMI), neck length and shoulder width. Correlation between measures of
of Surgery1, Cancer Research Institute2 Seoul National University College of body habitus and surgical outcomes with respect to operation time, number of
Medicine, Seoul, Korea retrieved central nodes, bleeding counts and postoperative complications were
retrospectively analyzed.
Purpose: Laparoscopy-assisted pylorus preserving gastrectomy (LAPPG) is one
therapeutic option for early gastric cancer with preservation of gastric function. Results: Total 217 patients underwent a less than total thyroidectomy and 135
The aim of this study is to evaluate the feasibility of robot-assisted pylorus patients underwent a total thyroidectomy. In less than total thyroidectomy
preserving gastrectomy (RAPPG) for early gastric cancer. cases, 177 patients were normal weight (BMI<25, NW), 35 patients were
overweight (25≤BMI<30, OW), and 5 patients were obese(30≤BMI, OB). In
Patients & Methods: Between June 2008 and October 2010, 11 consecutive total thyroidectomy cases, 105 patients were NW, 24 patients were OW, and
patients who underwent RAPPG were analyzed. Indication for surgery was 6 patients were OB. In terms of less than total thyroidectomy, operation time,
preoperately diagnosed as cT2 or less and cN0 (AJCC/UICC 7th). After bleeding counts showed no significant differences between three BMI groups.
informed consent, surgery was performed using da Vinci surgical system. The neck length showed positive correlation with the console time in less than
Results: All RAPPG cases were performed successfully without open or total thyroidectomy. In terms of total thyroidectomy, total operation time
laparoscopic conversion. The mean operation time and console time were and working space time took longer in OB. However, the number of retrieved
257 and 135 minutes. There were 2 (18.2%) morbidiy cases of intra-luminal central nodes and postoperative suppressed Tg level showed no significant
bleeding and wound complication. Gastric stasis is not observed in this study. differences. The shoulder width showed positive correlation with the total
Estimated blood loss was 46.1 ± 33.4 ml (Mean ± SD). Sips of water and semi- operation time, working space time, console time and the number of retrieved
fluid diet were started on postoperative day 3.3 and 4.3. Mean postoperative central nodes. The postoperative complication showed no significant differences
hospital stay was 7.7 days. All 11 patients were T1N0 (AJCC/UICC 7th) lesion between three BMI groups and it showed no significant correlation with neck
in final pathology report. The mean number of retrieved all lymph nodes and length or shoulder width.
LN stations 6 were 35.0 and 4.6, respectively. Conclusion: Body habitus makes impact on the robotic operation time. However,
Conclusion: RAPPG for early gastric cancer is a feasible technique in terms of robotic thyroidectomy with sufficient working space can be performed safely
morbidity and lymph node dissection. But advantage of RAPPG over LAPPG is with similar surgical stage and without increasing intraoperative bleeding or
not analyzed in this study because of the number of cases is limited. Our result postoperative complication even in obese patients.
prompts a prospective clinical trial for the role of RAPPG.
S017: EXPERIENCE IN 17 CASES OF ROBOTIC LIVER RESECTION
S015: COMPARISON OF PERIOPERATIVE OUTCOMEAS BETWEEN Ningxin Zhou, Quanda Liu, Junzhou Chen Institute of Hepatobiliary &
CONVENTIONAL TOTAL LAPAROSCOPIC LIVER RESECTION AND Gastrointestinal Diseases, PLA Second Artillery General Hospital
ROBOT-ASSISTED LAPAROSCOPIC LIVER RESECTION Chung Ngai Tang, Objectives: To summarize the experience of robotic hepatectomy using the da
MBBS FRCS, Eric C.H. Lai, MBChB MRCSEd FRACS, George P.C. Yang, Vinci Surgical System.
MBBS MRCSEd FRACS, Oliver C.Y. Chan, MBChB MRCSEd FRCS, Michael
K.W. Li, MBBS FRCS Department of Surgery, Pamela Youde Nethersole Methods: The clinical data of 17 patients undergoing robotic hepatectomy from
Eastern Hospital, Chai Wan, Hong Kong SAR, China January 2009 to July 2010 were reviewed.
Introduction: To compare the short term outcome between conventional total Results: Seventeen patients undergoing robotic hepatectomy were 55±16
laparoscopic liver resection and robot-assisted laparoscopic liver resection. years (range 27-84 years), and with 8 male patients. The indication of robotic
hepatectomy were hepatocellular carcinoma (3), cholangiocarcinoma (3,
Methods & Procedures: A non-randomized comparative study was conducted on Bismuth IIIb type Klatskin tumor 1, and intrahepatic cystadenocarcinoma 2),
49 consecutive patients, who underwent conventional total laparoscopic liver metastatic liver tumors (3), benign liver tumor (4, hepatic hemangioma 3, and
resection (n=17) and robot-assisted laparoscopic liver resection (n=32) between biliary cystadenoma 1), and left hepatolithiasis (4). Four cases with primary
October 1998 and January 2011. benign liver tumors included liver hemangioma (3) and biliary cystadenoma
16 6 TH ANNUAL MIRA CONGRESS May 11-13, 2011
(1); 12 cases with primary malignant liver tumors included hepatocellular S019: ROBOTIC RECTAL CANCER SURGERY VERSUS LAPAROSCOPIC
carcinoma (HCC) (9), and biliary carcinoma (3). The liver metastases were RECTAL CANCER SURGERY IN A SINGLE CENTER EXPERIENCE:
from gallbladder cancer (4 cases), periampullar cancer (3), gastric cancer (1) and SHORT TERM OUTCOMES ANALYSIS Irinel Popescu, MD PhD FACS,
rectal cancer (1). The robot-assisted surgical procedures consisted of anatomical Victor Tomulescu, MD PhD, Catalin Vasilescu, MD PhD, Serban Vasile, MD,
left hemihepatectomy (2), left lateral lobectomy (5), partial or wedged resection Olivia Sgarbura, MD PhD, Vlad Herlea, MD PhD Fundeni Institute of Digestive
(7), and s5a segementectmoy (1), together with other simultaneous robotic Diseases and Liver Transplantation
procedures managing the primary diseases or comorbidities in 12 cases. The Introduction: Laparoscopic rectal surgery is a challenging procedure, and always
average operative time for hepatectomy was 280min, and average intraoperative there are places for technical improvements in relation to its proximity to
blood loss was 150ml. Intraoperative massive bleeding occurred in 3 patients: delicate structures such as the pelvic nerves and the reproductive organs and
2 patients with giant hemangioma resulting in open conversion (11.8%). the difficulties of working in a narrow space. The dissection deep into the
Pringle’s inflow occlusion was used for 4 patients undergoing hepatectomy, pelvis to accomplish a correct total mesorectal excision (TME) and obtaining a
and the reciprocal method of sequential suturing hepatic parenchyma and specimen with intact margins and a cylinder shape is also technically demanding.
dissecting using Harmonic scalpel for left lateral hepatectomy was performed Theoretically, improved visualization and dexterity using robotic endoscopic
for 4 patients. The mean hospital stay was 7 days (5-16 days). Postoperative surgical devices may benefit patients by making laparoscopic operations easier.
complications occurred in 2 patients (11.8%, intraabdominal bleeding in 1,
and severe pulmonary infection in 1), which were managed conservatively. The Methods: A series of 84 consecutive patients with laparoscopic resection
mortality rate was 0%. (between 1995-2010) and 52 consecutive patients with robotic resection
(between 2008-2010) for primary rectal cancer were analyzed. Hartmann’s
Conclusions: Robotic hepatectomy is safe, feasible and efficacious. Exploration of procedures were excluded. Clinical and pathologic outcomes were reviewed
innovative techniques compatible to robotic surgical system, such as bleeding- retrospectively.
control maneuver, is mandatory for future robotic liver resections.
Results: In the laparoscopic group (LG), 50 anterior rectal resections (ARR),
S018: ROBOTIC SLEEVE GASTRECTOMY. A BETTER APPROACH FOR 34 abdominal perineal resections (APR) were performed while in the robotic
THE UPPER GASTRIC DISSECTION. Jose Manuel Fort, PhD, Ramon group(RG) there were 41 ARR and 11 APR. The median operative time was
Vilallonga, PhD, Manel Armengol, PhD Universitary Hospital Vall d’Hebron. 182 min (140-220 min) in LG and 208 min (180- 300 min) in RG p=0.0002).
Barcelona. No statistically significant difference was noticed between the groups in terms
of conversion, morbidity, anastomotic leak and postoperative stay rates. Margin
Objective: The application of robotic techniques has been reported for bariatric
clearance was obtained in all patients and the median number of removed lymph
operations like laparoscopic Roux-en-Y gastric bypass and laparoscopic
nodes was similar: 11.37 in RG vs 11.07 in the LG (p=0.65) with a higher rate
adjustable gastric banding, and more recently (august 2010) for LSG. Novel
of metastatic lymph node involvement in laparoscopy (p=0.0012). Blood loss
techniques such as laparoscopic sleeve gastrectomy (LSG) are now used for the
was higher in LG (150 ml vs. 100 ml; p=0.0001). There were 5 (5.9%) local
treatment of morbid obesity. In fact, the only publish article to our knowledge
recurrences in the LG at a median follow- up of 27.5 months and 2 (3.84%) in
has been in august 2010. There is now enough experience with LSG in our
the RG at a median follow-up of 12 months (p=0.43).
group and we had the possibility to begin robotic sleeve gastrectomy. We report
herein our initial experience with LSG performed with the use of the Da Vinci Conclusions: Robotic surgery for rectal cancer proved to be safe and efficient.
surgical system where we have found to be easy, feasible especially in the upper Technological advances of robotic approach compared to laparoscopy allowed
gastric part. better ergonomics, more refined dissection, easier preserving of hypogastric
nerves and less blood loss. Long term outcomes are to be assessed in prospective
Method: Eighteen consecutive patients underwent LSG with the use of the Da
randomized studies.
Vinci surgical system by the same surgical team. Surgical techniques followed
the principles of standard LSG. We used three 12 mm standard trocars and S020: ROBOTIC GASTRIC BYPASS: REDUCING ANASTOMOTIC
a 8mm DaVinci trocar to perform this novel technique. The 8-mm metallic COMPLICATIONS Francois Pugin, MD, Pascal Bucher, MD, Monika Hagen,
robotic ports were inserted through the standard, disposable 12-mm trocars. MD, Nicolas Buchs, MD, Gilles Chassot, MD, Philippe Morel, MD University
Preparation of the stomach was performed by the console surgeon alone and its Hospitals Geneva
division with the staplers by the patient-side surgeon. We completed a sleeve
gastrectomy at 2 or 5 cm from the pylorus with a 36F boggie inside the stomach Introduction: Gastric bypass is a recognised therapy for morbid obesity. The
and performing stappeling through a standard 12 mm trocar. A complete robotic laparoscopic approach offers the advantages of shorter hospital stays, lower
prolene® suture for reinforcment. The upper GI part is perfectly visible and incision hernia rate, and less pulmonary complications. Nevertheless the rate of
suturing becomes very easy with the Da Vinci System. A drain is finally placed anastomotic complications remains non-negligible, possibly related to the use of
next to the sleeve. stapling devices. The aim of this study is to evaluate if robotically "hand sewn"
anastomoses have a lower leak/stricture rate than stapled anastomoses.
Results: Twenty patients (2 men and 18 women) with a mean age of 44.4 years
(17-63) and a mean body mass index (BMI) of 48.0 kg/m2 were operated by Methods: Prospective study comparing laparoscopic versus robotic-assisted
Robot. Mean total operative time (including docking time) was 104.1±15.3 gastric bypass for morbidly obese patients. The primary end-point was
min. Mean set-up time was 35 minutes and mean docking time was 6 min. There anastomotic complications (leak and stricture). All patients selected for a gastric
were no conversions. Complete robotic prolene® suture for reinforcement bypass with a BMI over 40 were included in this study. Exclusion criteria were
was performed in 14 patients. Also Seamguald® was used as reinforcements contraindication to laparoscopy. The gastrojejunostomy and jejunostomy were
in 6 patients. Peri-operative morbidity and mortality was zero. Mean time performed manually in the robotic group using the DaVinci surgical system and
for discharge was 4.16 days. We had a patient who required a conversion to with circular and linear staplers in the laparoscopic group respectively.
laparoscopic gastric by-pass after one month because of an unusual complication Results: 502 patients were included in this study (334 in the laparoscopic
of curling stomach. Mean BMI at 3 months post-operatively was 35.8± 25.6%. group, 168 in the robotic group) with a mean age of 41 years and a mean BMI
The procedure can be completed with only one assistant and with four trocars of 44. The female to male ration was 4:1. There was a significantly lower
instead of five in LSG. leak rate (0% vs 3.3%, p<0.05) and stricture rate (0% vs 6.6%, p<0.01)
Conclusions: Robotic laparoscopic sleeve gastrectomy is a feasible and safe in the robotic group compared to the laparoscopic group. Fewer pulmonary
approach. In experienced laparoscopic hands it is still an efficient surgical complications were recorded in laparoscopic group (n =10, 3,0%) than in the
technique for the treatment of morbid obesity. No added operating time for the robotic group (n=7, 4.2%), but the difference was non significant. There was
procedure has been reported. The application of robotics to this type of surgery no mortality in both groups.
might have less obvious advantages than with LRYGBP but to us, the dissection Conclusion: In our experience the use of a robotic surgical system allows to
of the upper part of the stomach is easier. However, to our knowledge few reduce anastomotic complication rate of minimally invasive gastric bypass.
groups use the Da Vinci system in the world. Our Group has considered as a Longer follow-up is needed to confirm these promising results. The gastric
novel and first approach before being involved in Robotic Gastric Bypass. bypass is a an excellent indication for robotics in visceral surgery.

www.mirasurgery.org 17
Oral Abstracts
S021: COMPARATIVE EVALUATION BETWEEN THE ROBOTIC AND Were recorded good oncological results about proctocolectomies: after a median
OPEN ULTRA-LOW ANTERIOR RESECTION IN PATIENTS WITH follow up of 40 months the overall survival for all stage was 86.7% and the
LOWER RECTAL CANCER Jin C Kim, MD, Kyung H Kim, MD, Sung S DFS was 69.6%. One local relapse occured. No differences were reported in
Yang, MD, Jae Y Kwack, MD, Tae Y Chang, MD, Seok B Lim, MD Department comparison to a group of 24 laparoscopic rectal resections performed during
of Surgery, University of Ulsan College of Medicine and Asan Medical Center, the same period with the same patient’s features, the overall survival was 95.8%
Seoul 138-736, Korea (p=0.373), the DFS was 91.7% (p=0.108), without local recurrence (p= 0.383).
Objective: The efficacy of robotic approach was comparatively evaluated with that Conclusions: We believe that robotic surgery is advantageous in the steps of
of open method in the ultralow anterior resection (uLAR) of low rectal cancers. vascular dissection and TME. Prospective trials will be needed to validate
oncological and functional results.
Patients & Methods: A total of 30 patients with robotic uLAR and 29 patients with
open uLAR were prospectively included. Both groups underwent complete S023: TELELAP ALF-X- THE FUTURE OF ABDOMINAL SURGERY (BACK
total mesorectal excision. The former group constituted the ninitial seven TO THE FINGERTIPS) Michael Stark, MD, Emilio Morales, SOFAR SpA The
patients using hybrid approach and the latter 23 patients using total robotic New European Surgical Academy; Telelap ALF-X SURGICAL ROBOTICS
uLAR. The laparoscopic abdominal dissection was performed preceding robotic Department
pelvic dissection in the hybrid approach. The open group included more male,
patients with preoperative chemoradiation, and infiltrating tumor compared to Traditionally, surgeons have used their fingers to palpate and manipulate tissues.
the robotic group. The mean basal metabolic index (BMI) in the robotic group When endoscopy and, later, robotic surgery were introduced, the use of the
was somewhat higher than that in the open group (23.5 ± 2.1 vs. 22 ± 3.2, P = fingertips – one of the most sensitive parts of the body – was abandoned and
0.044). sight became indirect.
Results: The mean operation time was longer in the robotic group compared To overcome this, a new surgical system, the Telelap Alf-x, has been developed.
to the open group (232 ± 49 min vs. 116 ± 16 min, P < 0.001). However, the This system combines the advantages of laparotomy and endoscopy. Among its
mean number of harvested lymph node, level of anastomosis, start of formed features are tactile sensing, a high degree of versatility, 3D vision, non-tremor
diet, postoperative complications, and hospitalization did not differ between and an eye-tracking system.
the two groups. The mean operation time did not differ between the hybrid and In order to assess the validity of this system, experimental preclinical procedures
total robotic approaches (233.1 ± 53.6 min vs. 234.5 ± 49 min, P = 0.951). (hysterectomy, salpingo-oophorectomy, myomectomy, partial and radical
Operative complications occurred in three patients, i.e., minor rectal wall nephrecto¬my, total pelvic exenteration and cholecystectomy) were performed.
perforation, and the internal iliac vein and marginal artery injuries, respectively.
A conversion to open surgery was performed in a case with the marginal artery The parameters examined were:
injury. Nevertheless, the robotic approach enabled excellent levator-sphincteric 1. The use of the newly designed handles, surgical arms and instruments
dissection even in patients with narrow pelvis and high BMI. 2. Haptic force transmission
3. Ergonomic aspects
Conclusions: The uLAR using total robotic approach can efficiently be 4. Safety and reliability
accomplished to achieve competent outcome, ensuring excellent operative field 5. The 3D Stereo Vision system
and less physical burden to the surgeon. The RCT-based comparative study and 6. Docking time
long-term follow-up may further enlighten the utility of robotic uLAR. 7. Durability of the re-usable instruments
8. Capability of complex surgical steps
S022: ROBOTIC COLORECTAL PROCEDURES: OUR EXPERIENCE G 9. Economic aspects (all elements are reusable)
Spinoglio, MD, R Quarati, MD, F Priora, MD, LM Lenti, PHD, F Ravazzoni,
PHD, V Maglione, MD Division of Oncologic General Surgery, ASO "SS Regarding all these parameters system performance seems to be superior to
Antonio e Biagio e Cesare Arrigo", Alessandria , Italy. traditional endoscopic surgery.
Aim: The robotic colorectal surgery enhances the advantages of laparoscopy Detailed reports concerning these parameters as well as the results compared to
providing a three dimensional view, ambidextrous capability, tremor elimination, common endoscopic operations and a video describing the usage of the system
multiple degrees of freedom instruments. Therefore we have used the robotic will be presented. This system proved efficient, reliable and useful. Its use and
system for colorectal surgery since 2005. Our results are reported below. further development promise a simplification of the performance of complex
surgical procedures. The simplicity of its usage; tactile sensation and 3D vision
Methods: We performed 36 right colectomies, 36 left colectomies and 49 make surgery as similar as possible to traditional laparotomy, without its known
proctocolectomy: from March to April 2010 we used the new model of robot disadvantages, which result from the abdominal wall incision. Hence the system’s
da Vinci ® Si HD was introduced. For right colectomies we standardized our description as a tool bringing about a “Renaissance of Abdominal Surgery”.
technique with an initial vascular dissection and lymphadenectomy along the
mesenteric axis and subsequent colectomy with intracorporeal lateral-lateral S024: SURGICAL, ONCOLOGIC AND FUNCTIONAL OUTCOMES IN
ileo-colic mechanical anastomosis. For left and proctocolectomies in the second PATIENTS WITH A GLEASON SCORE 8 OR HIGHER UNDERGOING
series, we standardized our procedure by using the Kim’s a trocar’s layout ROBOTIC-ASSISTED RADICAL PROSTATECTOMY. Apostolos P Labanaris,
and robotic steps: starting from the vascular dissection, rectal dissection in MD PhD, Vahudin Zugor, MD PhD, Jorn H Witt, MD PhD Department of
the mesorectal plane proceeded in accordance with Heald’s total mesorectal Urology and Pediatric Urology - Prostate Center Northwest, St. Antonius
excision (TME) principles and then releasing the left colic flexure. Medical Center, Gronau, Germany
Results: Right colectomy: the mean operative time was301.2 (145-540) min. Introduction: During the past years robot-assisted radical prostatectomy (RARP)
Just one conversion occurred. Specimen length was 28.36+-11 cm(range 18- has become profoundly popular and with the expanding experience obtained
50), the number of harvested lymphnodes was 23 +-11 (13-45). No surgical with it the selection criteria for the procedure have also widened and included
complications occurred which required reintervention. The mean time of more challenging cases. The objective of this study is to assess the surgical and
discharge was 6 (range 4-13) days. Left colectomy: the mean operative time oncologic outcomes in patients with a Gleason score 8 or higher prostate cancer
was 336.0 (255-540) min. Three conversions occurred. There were seven (PCa) undergoing RARP.
diverticulitis. Specimen length was 19.5+-10 cm (range 13-43), in case of
malignancy the number of harvested lymphnodes was 16.9 +-11 (8-43). Surgery Methods & Procedures: The records of N=2000 men who underwent RARP
related morbidity was 1/36: one case of ileal occlusion by adhesions. The mean at a certified robotic institute from February 2006 to April 2010 were
time of discharge was 6 (range 4-15) days. Proctocolectomy: median operative retrospectively reviewed. A total of N=137 patients were identified as having
time 428 (250-650) min. Seven conversions to open procedures occurred. a Gleason score 8 or higher. A comparison was performed between the overall
Specimen length was 22.8+-5 cm (range 11-35) the number of harvested patient cohort and the aforementioned patients. The parameters analyzed
lymphnodes was 19 (5-52). In 67% of patients a neaoadjuvant therapy was included: age, body-mass index (BMI), prostate weight, PSA values, percentage
perfomed. Surgery related morbidity was 5/49 which required a reintervention, of PCa found in the prostate specimen, skin-to-skin operative time, estimated
No death occurred. The mean time of discharge was 10 (range 8-30) days. blood loss, minor (Clavien’s grade I–IIIa) and major complications (Clavien’s

18 6 TH ANNUAL MIRA CONGRESS May 11-13, 2011


grade IIIb-IVa), length of catheterisation, pathologic stage, lymph node status, Material & Methods: From 03/05 to 04/10, 60 patients (39 M/21 W; 27 right and
positive margin status and continence (defined as no pad use). 33 left kidneys; mean age 60 yr) underwent RAPN with the DaVinci® system :
patients in a 60° flank position, 5 transperitoneal ports were used (2x12, 2x10,
Results: The median age of the patients was 63 / 65 years, median BMI 26.7 kg/
1x5 mm). The artery was clamped with a bulldog before incising the renal
m2 / 28.3 kg/m2 and median prostate weight 56.1 gr. / 52.5 gr. The median
parenchyma with the cold scissors. After removing the specimen, 4/0 resorbable
operative time was 156 min / 156 min and estimated blood loss was 160ml /
stitches were applied to the main vessels and calyx. Complementary sealant
166ml. and. Minor complications were noted in 11.4% / 13.7% of cases, major
(BioGlue®, Tachosil®) was applied to the renal parenchyma, before releasing
in 1.3% / 1.4% and the length of catheterisation was 5.5 days / 7.1 days. A
the clamp. Additional parenchymal suture was applied if necessary. Gerota’s
statistical difference of the parameters analyzed was observed in PSA values
fascia was sutured in order to retroperitonealize the kidney. No suction drain
10.3 ng/ml / 20.8 ng/ml (p<0.05), organ-confined disease 73.5% / 18.9%
was used.
(p<0.001), extraprostatic extension in 25.2% / 81.1% (p<0.001), percentage of
PCa found in the prostate specimen 16.1% / 38.2% (p<0.05), positive surgical Results: Mean tumor size : 26 mm ; ischemic time 28 min; blood loss was
margins 8.9% / 32.8% (p<0.001) and positive lymph nodes 3.2% / 19.7% minimal (no transfusion). CT scans performed within the first postoperative
(p<0.05). At 12 months, 92.8% / 90.5% were continent. week showed no hematoma and good renal function without urinary leak.
Histology showed 49 carcinomas, 7 oncocytomas, 4 AML. All surgical margins
Conclusions: Our findings suggest that although RARP in patients with a Gleason
were negative.
score 8 or higher PCa is a safe surgical procedure with limited complications
and good functional results, patients should be made aware of a potential risk Complications : thrombo-embolism (2), urinary infection (2). 2 arterial aneurism
of positive surgical margins before undergoing the procedure. Despite these required selective embolization. At 20 months mean follow-up, no recurrence
oncologic outcomes observed we do not believe RRLP is a contraindication in was observed.
this cohort of patients. Conclusions: Owing to the benefits of 3D vision and the seven degrees of
freedom of the instruments offered with robotics, the surgeon can perform
S025: ROBOTIC-ASSISTED LAPAROSCOPIC LIVING DONOR
complex procedures such as RAPN more easily than in standard laparoscopy.
NEPHRECTOMIES : EXPERIENCE IN 100 CASES J. Hubert, MD, M
Our promising results need to be confirmed by further comparative series, but
Ladriere, MD PhD, C. Waked, MD PhD, G Chopin, MD, P Eschwege, MD
robotics may have an impact on partial nephrectomy similar to its impact on
PhD, P Eschwege, MD PhD, L Frimat, MD PhD, M. Kessler, MD Dept.
prostatectomy.
of Urology and Nephrology, CHU Nancy-Brabois, allée du Morvan, 54511
Vandœuvre les Nancy, France S027: ROBOTIC ASSISTED LAPAROSCOPIC TRANSPERITONEAL
Introduction & Objectives: Entirely robot-assisted laparoscopic donor PYELOPLASTY : 10 YEARS EXPERIENCE, 100 CASES J. Hubert, MD,
nephrectomies (RALDN) have been adopted for 8 years at our institution, M Chammas, MD, C. Egrot, MD, N Hubert, MD, P Eschwege, MD PhD, J
allowing an increase in renal donation. We here review our initial experience of Hubert Department of Urology, CHU Nancy-Brabois 54511 VANDŒUVRE les
perioperative morbidity in donors and early outcomes in recipients. NANCY, FRANCE.
Material & Methods: From January 2002 to January 2010, 100 patients : 60 Introduction: Dismembered pyeloplasty is the gold standard for uretero-pelvic
female, 40 male; 86 left kidneys; mean age 46 yr; BMI 25 (>30 in 11 cases), junction syndrome. Laparoscopic dismembered pyeloplasty has been developed
were operated on with the DaVinci® system, using four ports (three for the but is a challenging procedure, which can be facilitated by robotic assistance.
robotic arms and one for the assistant). Collateral veins were ligated, and Our objective is to evaluate the results of laparoscopic robotic pyeloplasty which
the renal arteries and veins clipped, after completion of ureteral and renal we developed in 2000 in experimental surgery and has become the standard
dissection. The kidney was removed via a suprapubic Pfannenstiel incision. A procedure in our institution since 10 years.
complementary running suture was carried out on the arterial stump to secure
the hemostasis. Transplantation was carried out immediately afterwards. Material & Methods : from November 2001 to January 2007, 100
transperitoneal laparoscopic robotic assisted pyeloplasties for UPJ obstruction
Results: All RALDN (22 kidneys with 2 and 4 with 3 arteries) were carried were performed in 99 patients (58 female, 41 male, mean age 38.4 yr) : 36
out entirely laparoscopically, without complications and with minimal blood left/64 right ; one bilateral). This was a primary treatment in 92 cases, a
loss (mean Hb decrease 0.7 g/dl ; no transfusion). Surgery time, warm and 2nd approach in 6; 3rd in one and 4th in one cases. Four ports were used:
cold ischemia times were 177 min 4,98 min and 202 min, respectively. Post- 3 for the robotic arms (1x12, 2x10 mm) and one (12 mm) for the assistant.
operative complications : 2 wound infection, 1 cholecystitis, 2 phlebitis and The retroperitoneal incision was minimal in all cases. Anastomosis was
2 peripheral embolism, 1 pyelonephritis, 1 chylous ascitis. Pre-op / 1 month completed with 6/0 running sutures and a ureteral JJ stent was introduced
creatinine : 90±17 / 110 ±20 μmol/l. Average hospital stay: 4.3 days. peroperatively. No suction drain was used. Gerota’s fascia was sutured in
Recipients: mean age 43 Yr, 64 male, BMI 24; None but two (only 1 dialysis order to retroperitonealize the anastomosis. Clinical control and IVU with
session required) of the transplant recipients had delayed graft function. lasix® were performed 3 and 12 months after surgery.
Mean recipient creatinine clearance at 6 and 12 months: 56.7 & 57.5 ml/min. Results: All the pyeloplasties were completed laparoscopically with the robot.
Recipients complications comprised 2 phlebitis, 1 peripheral embolism, 3 There was 1 open conversion (# 20). An inferior polar pedicle had to be
cystitis ; 1 hematoma, 1 lymphocele and 4 ureteral necrosis required surgical uncrossed in 58 cases. Mean operative time was 118.5 min (including antegrade
treatment. JJ placement) ; mean suturing time 33.7 min ; blood loss was minimal (<40 ml);
Conclusions: RALDN can be safely carried out, with excellent short and long mean hospital stay 5.23 days. Bladder catheter was removed at day 3.1. There
term results for both donor and recipient. Robotics enhances the laparoscopist’s were 5 post-operative cystitis which resolved with antibiotic treatment. Average
skills and enables the surgeon to dissect meticulously and to prevent problematic length of follow-up was 23.7 months. At 3 and 12 months follow-up all the
bleeding more easily while allowing the surgeon to work under better patients were clinically improved, and of the 67 and 43 available IVUs there was
ergonomic conditions. a 93% and 97 % improvement respectively.
Conclusion: Our clinical results for robotic-assisted Anderson-Hynes pyeloplasty
S026: ROBOT-ASSISTED PARTIAL NEPHRECTOMY (RAPN).
appear to be at least equivalent to those obtained in open surgery. The technique
EXPERIENCE IN 60 CASES. E Barbier, PE Theveniaud, N Hubert, MD,
was improved over the years and is now standardized. Instruments are limited
P Eschwege, MD PhD, J Hubert, MD PhD Urology Dept, CHU de Nancy-
to 3 (bipolar forceps, hot scissors, microforceps) in order to reduce the costs.
Brabois. Allée du Morvan, 54511 VANDOEUVRE-LES-NANCY, France
Bladder catheter and JJ stent are removed after 2 and 15 days respectively.
Introduction: Laparoscopic partial nephrectomy (LPN) is an accepted alternative Minimal invasive dissection, quality of the sutures, facilitation of all the
to open partial nephrectomy but requires a steep learning curve and is still technical steps, reproducibility and ergonomy are the major advantages of
a challenging procedure that only leading teams have developed routinely. robotic assistance.
Robotics may improve the different operative steps and allow to perform it more
easily and in more complex cases. We report our 5 years experience in robotic-
assisted LPN (RAPN).
www.mirasurgery.org 19
Oral Abstracts
S028: ROBOTIC PROSTATECTOMY. FEASIBLE AND SAFE IN PATIENTS teams, 26 to 36 cases according to 3 (23.1%) and over 37 cases according to
WITH PREVIOUS ABDOMINAL SURGERY. Apostolos P Labanaris, MD 2 (15.4%). The greatest technical difficulties reported when performing a
PhD, Vahudin Zugor, MD PhD, Jorn H Witt, MD PhD Department of Urology radical prostatectomy were: robot preparation in 2 (15.4%) cases, sparing
and Pediatric Urology, Prostate Center Northwest, St. Antonius Medical the neurovascular bundles in 2 (15.4 %), identifying the bladder neck in 5
Center, Gronau, Germany (38.4%) and identifying and dissecting the seminal vesicles in 7 (53.8%).
CONCLUSIONS Up to March 26, 2010, 1692 operations, mostly radical
Introduction: With the advent and expanding experience obtained with robot-
prostatectomies, were conducted using the da Vinci robot in our country. This
assisted laparoscopic radical prostatectomy (RALP), the capabilities of this
questionnaire served to identify the main problems encountered during the
technique and selection criteria for the procedure have also widened and
installing of a robotic urological surgery programme.
included more challenging cases. The objective of this study is to evaluate the
surgical, oncologic and functional outcomes in patients with previous abdominal S030: ROBOTIC MITRAL VALVE REPLACEMENT Changqing Gao, MD PLA
surgery undergoing RALP. General Hospital
Methods & Procedures: The records of N=2000 men who underwent RALP Background: Since 2007, we have performed over 380 cases of robotic cardiac
at a certified robotic institute from February 2006 to April 2010 were operations, in which robotic mitral valve surgery was performed in 66 cases.
retrospectively reviewed. A total of N=160 (8%) patients had undergone a In this present, we determined the safety and efficacy of robotic mitral valve
previous abdominal operation. A comparison was performed between the replacement using robotic technology.
overall patient cohort and the aforementioned patients. The parameters analyzed
included: age, body-mass index (BMI), prostate size, PSA values, bilateral Methods: From January 2007 through August 2010, 66 patients underwent
neurovascular bundle (NVB) preservation, Gleason score, pathologic stage, robotic mitral valve repair/repacement. Mean age was 48.3±14.8 (range 19–70
positive surgical margins (PSM), percentage of prostate cancer (PCa) found in years) years and 75% were male, in which 22 patients with mitral valve stenosis
the specimen, blood loss, minor (Clavien’s grade I-IIIa) and major complications underwent mitral valve repacement. Surgical approach was through 4 right chest
(Clavien’s grade IIIb-IVa), skin-to-skin operative time, continence (defined as ports with femoral perfusion, aortic occlusion was performed with Chitwood
no pad use) and potency (defined as erections sufficient for penetration with or crossclamp, and antegrade cardioplegia was administered directly via anterior
without phosphodiesterase inhibitors) in 12 months. chest. Via 3 port incisions in the right chest and 2.5 to 3.0 cm working port, all
the procedures were completed with the da Vinci S robot.
Results: N=56 patients (35%) had undergone previous unilateral inguinal
hernia repair (N=34 cases with mesh), N=40 (25%) previous bilateral Results: All patients had successful robotic surgery. Mitral valve replacement
inguinal hernia repair (N=32 cases with mesh). N=10 (6.2%) previous gastric was in 22 patients, 16 of which had mechanical valve, 6 had tissue valve.
operation, N=24 (15%) previous appendectomy, N=16 (10%) previous Mitral valve repair was performed in 44 patients. The mean CPB time and
intestine resection and N=10 (10%) umbilical hernia repair with mesh. The aortic crossclamp time were 137.1±21.9 (105 to 168) min and 99.3±17.4
age of the patients was 63 / 64 years old , BMI 26.7 kg/m2 / 27.9 kg/m2 and (80 to 133) min, respectively. There no operative deaths, stroke, or other
prostate weight 56.1 gr. / 52.9 gr. PSA values were 10.3 ng/ml / 11.8 ng/ complications. There were no incisional conversions. All patients were followed
ml. NVB preservation was performed in 65.7% / 36.8% of cases. A Gleason up Echocardiographically.
score < 7 was noted in 42.8% / 25%, a Gleason score 7 in 47.7% / 70% and Conclusions: Totally endoscopic mitral repacement can be performed safely with
a Gleason score > 7 in 9.5% / 5 %. PCa was confined in 74% / 60% and robotic technology in selected patients, and surgical results are excellent.
locally extended in 26% / 40% of patients. The percentage of PCa found in
the prostate specimen was 16.1% / 18.9% and positive surgical margins were S031: MID-TERM FOLLOW UP AFTER ROBOTICALLY
encountered in 8.9% / 5%. The estimated blood loss was 160ml / 186ml and ASSISTED TOTALLY ENDOSCOPIC REPAIR OF INTRAATRIAL
median operative time was 156 min / 171 min. Minor complications were COMMUNICATIONS Nikolaos Bonaros, Stepan Cerny, Felix Weidinger,
noted in 11.4% / 14,3% of cases and major in 1.3% / 3,75%. The length of Christoph Steger, Martin Michel, Silvana Mueller, Thomas Bartel, Johannes
catheterisation was 5.5 days / 5.7 days. At 12 months, 92.8% / 86.2% were Bonatti, Thomas Schachner Department iof Cardiac Surgery, Innsbruck Medical
continent and 66.2% /58,7% of preoperative potent patients who underwent University
NVB preservation were potent.
Background: Repair of atrial septal defects is increasingly performed via mini-
Conclusions: RALP in patients with previous abdominal surgery is feasible and thoracotomy or in a totally endoscopic fashion using robotic technology.
safe. Although this patient cohort can still pose increased challenges even to Perioperative results of small series of totally endscopic ASD-repair have been
experienced operators, the surgical, oncologic and functional outcomes are reported in the literature but the long-term results of the procedure are still
similar to patients without a history of previous abdominal surgery. unknown.
S029: KEY AREAS IN THE LEARNING CURVE FOR ROBOTIC Methods: Seventy two patients (21 male, 51 females, median age 38 (16-
UROLOGICAL SURGERY: A SPANISH MULTICENTRE SURVEY Jesus 62)) were operated at two institutions using the Da Vinci robotic system.
Moreno Sierra, MD PhD, Elena Ortiz Oshiro, MD PhD, Isabel Galante Romo, Pathology of interatrial communication included an atrial septal defect II in
PhD, Jose Luis Senovilla, PhD, Ivan Mansilla Garcia, Maria Escudero Romo, 56 patients, a patent foramen ovale in 15 patients and a sinus venosus defect
Angel Silmi Moyano, MD PhD Hospital Clinico San Carlos - Universidad in 1 patient. Nine of the patients had a malpositioning of an atrial septal
Complutense de Madrid occluder which had to be surgically removed. Twenty nine patients received
a patch reconstruction and 43 of the patients had a direct closure. The major
Introduction: The number of robotic-assisted procedures performed in Spain perioperative and mid-term results were evaluated by echocardiography as
is rapidly increasing despite a lack of consensus criteria for training and well as clinical follow-up.
credentialing. This national multicenter study was designed to analyze the
different areas of the robotic urological surgery learning curve. Results: Median operation time was 310 min (186-650), cardiopulmonary bypass
time was 135 min (55-269), and aortic cross clamp time was 70 min (33-164).
Material & Methods: A questionnaire was sent to all 13 urology units in Spain with One conversion to mini-thoracotomy was needed. Two patients had to be
an active robotics programme requesting information on training and problems reoperated due to residual shunt detected before discharge. The mean follow-up
encountered. was 29 months (0.25-94). No stroke, or other major cardiac event was reported
Results: In most centres, training programmes were animal-based; cadavers during follow-up. The median NYHA classification was 1 (1-3) during follow-up
were used at only 2. Prior experience in open and/or laparoscopic surgery was and the median ejection fraction was 70% (65-80). No additional residual shunt
reported by 10 of the groups (76.9%), and experience only in open surgery was detected after discharge.
by 2 (15.4%) or robotic surgery alone by 1 (7.7 %). The procedure with Conclusions: The midterm resuls of robotically assisted totally endoscopic atrial
which the robotics programme was started in all 13 participating units was septel defect repair are very satisfactory and well comparable with conventional
radical prostatectomy. The number of cases needed to complete the learning and mini-thoracotomy approaches. Complex defects including removal of
curve for this procedure was: 20 to 25 cases according to 8 (61.5%) surgery malpositioned occluders can be repaired using endoscopic methods.

20 6 TH ANNUAL MIRA CONGRESS May 11-13, 2011


S032: ROBOTIC TOTALLY ENDOSCOPIC CORONARY ARTERY Results: Interventions were completed endoscopically in 27 (84%) patients
BYPASS GRAFTING ON THE ARRESTED HEART - TWO CENTERS’ and conversion to mini thoracotomy or sternotomy was required in 5 (16%)
EXPERIENCE WITH 305 CASES Eric J Lehr, MD PhD, Thomas Schachner, patients. Reasons for conversion included evacuation of clot from the pleural
MD, Nikolaos Bonaros, MD, Dominik Wiedemann, MD, Felix Weidinger, MD, space, anastomotic stenosis identified on intraoperative angiogram, anastomotic
David Zimrin, MD, Bartley Griffith, MD, Johannes Bonatti, MD University of bleeding, kinking of the graft at the middle anastomosis and intramural
Maryland School of Medicine, Medizinische Universitöt Innsbruck hematoma of LIMA. Total procedure time including on-table angiography was
349(185 - 625) minutes. Cardiopulmonary bypass and crossclamp times were
Objectives: Robotically assisted totally endoscopic coronary artery bypass grafting
158 (88 - 380) minutes and 110 (32-231) minutes respectively. Three (9%)
(TECAB) is emerging as an advanced minimally invasive method of surgical
patients underwent revision for bleeding, most commonly at the port sites.
coronary revascularization. The aim of this study is to review the surgical and
mid-term outcomes of TECAB performed on the arrested heart. Conclusions: Multivessel TECAB using sequential bypass grafting strategies is
feasible. These techniques broaden the spectrum of coronary artery disease
Methods: Between October 2001 and August 2010, 305 patients (age 60 [range
suitable for robotically-assisted totally endoscopic revascularization.
37 – 83], 229 [75.1%] male) all with low grades of systemic atherosclerosis)
underwent arrested heart TECAB by three surgeons at two institutions. All S034: ROBOTIC THORACOSCOPIC FIRST RIB RESECTION -
operations were performed with a surgical robot through 4 or 5 ports using PRESENTATION OF A SERIES OF PATIENTS Farid Gharagozloo, Marc
femoral cannulation and cardioplegic arrest delivered by an endoaortic occlusion Margolis, MD, Eric Strother, CSA, Barbara Tempesta, CRNP Washington
balloon. A total of 387 grafts were placed with 76 patients undergoing double Institute Of Thoracic And Cardiovascular Surgery; The George Washington
vessel TECAB and a triple bypass grafting procedure was performed in 3 University Medical Center
patients. TECAB was combined with a planned percutaneous intervention in 115
patients as part of a hybrid revascularization strategy. Objectives: First rib resection is the most effective treatment for Paget-Shroetter
Syndrome (thrombosis of the axillary-subclavian vein). Previously described
Results: There were no 30-day mortalities. Conversion to mini thoracotomy or techniques have included transaxillary, transthoracic, and infra/supraclavicular
sternotomy was required in 38 (12.5%) patients. Twenty-two (7.2%) patients approaches. These approaches are associated with an incidence of incomplete
underwent revision for bleeding, most commonly at the port sites. Intra-aortic rib resection and neurovascular complications. We report a minimally invasive
balloon pump for postoperative support was placed in 4 (1.3%) patients. Only 38 robotic thoracoscopic approach for resection of the first rib through the chest
(12.5%) patients developed atrial fibrillation and deep thoracic wound infection without dissection of the extra thoracic structures.
occurred in a single (0.32%) patient. Postoperative ventilation time was 8 hours
(0 – 349), duration of ICU stay was 20 hours (11 – 1048) and hospital length Methods: Over a 10 month period, 10 robotic first rib resections were performed
of stay was 6 days (3 – 54). There were 3 (0.98%) strokes and 2 (0.66%) aortic in 6 patients Pre-operative studies included CT scan of chest and bilateral
dissections. Hemofiltration or hemodialysis was necessary in 3 (0.98%) patients. angiography. The robot was introduced through three 2 cm incisions. The first rib
Follow up was complete in 294 (96.4%) cases. Early return to everyday activities was dissected using the robot. The right robotic arm was removed and replaced
after hospital discharge was noted: time to walking outside was 7 days (1 – 180), with a long thoracoscopic 6 mm kerasin which was used to divide the rib between
time to restarting general household activities was 14 days (2 – 360) and time the subclavian artery and vein. Following the division of the rib, the right robotic
to full recovery and resuming vigorous activities was 60 days (3-720). Survival, arm was re-positioned and the remainder of the procedure was performed
freedom from angina, and freedom from major adverse cardiac and cerebral events robotically. The division of the rib at its midpoint allowed for the rib to be pivoted
at five years was 99.5%, 90.2%, and 80.9% respectively. on the sternal and vertebral joints respectively. The rib was then dissected from
the scalene muscles and disarticulated at the respective joint. Success of the first
Conclusions: TECAB performed using remote access perfusion and cardioplegic rib resection and relief of thoracic outlet syndrome was assessed by subjective
arrest appears to be safe in selected patients. A major benefit is early return to symptom relief, objective physical examination, and post-operative angiography.
normal activities. Intermediate term results are comparable to conventional
CABG. Results: There were 10 total procedures in 6 patients with 4 of the patients
having staged bilateral first rib resections. bilateral procedures. There were
S033: SEQUENTIAL CORONARY BYPASS GRAFTS FOR ROBOTICALLY 4 men and 2 women. Mean age was 37 years. 9/10 had anterior thoracic
ASSISTED TOTALLY ENDOSCOPIC SURGICAL REVASCULARIZATION outlet syndrome with obstruction of the subclavian vein (Paget-Shroetter
OF MULTIVESSEL CORONARY ARTERY DISEASE Eric J Lehr, MD PhD, Syndrome). Immediate decompression of the subclavian vein and decrease in
Thomas Schachner, MD, Nikolaos Bonaros, MD, Dominik Wiedemann, MD, upper extremity swelling was seen in 10/10 patients (100%). Post-op venogram
Felix Weidinger, MD, Andreas R de Biasi, BS, Alina Grigore, MD, Mark Vesely, revealed a patent subclavian vein in all patients. Anti-coagulation was continued
MD, Griffith Bartley, MD, Johannes Bonatti, MD University of Maryland in 4-5/10 patients based on the presence of pre-op thrombus in the subclavian
School of Medicine, Medizinische Universitöt Innsbruck vein. There were no intra-operative or post-operative complications.
Objectives: Reported benefits of sequential coronary grafts that are advantageous Conclusions: Robotic thoracoscopic first rib resection is feasible. It represents
in robotically assisted totally endoscopic coronary artery bypass grafting an ideal approach to the resection of the first rib and scalenectomy through the
(TECAB) include conservation of conduit, reduced dependence on proximal chest thereby obviating the neurovascular complications that are associated with
aortic anastomoses, improved flow with increased runoff, more complete the transaxillary and supraclavicular approaches.
revascularization and long-term patency equivalent to single ITA grafting. The
aim of this study is to review the surgical outcomes of sequential coronary S035: ROBOTIC CARDIAC SURGERY IN GREECE Aristotelis Panos, PhD
bypass grafts performed completely endoscopically with robotic assistance. FECTS FMH, Fotis Milas, MD, Sylvio Vlad, MD 3rd Clinic for Cardiac Surgery,
Hygeia Hospital, Athens, Greece. La Tour Hospital, Geneva, Switzerland
Methods: Sequential grafts were performed in 32 (age 65 [range 43 - 73], 23
[72%] male) of 387 patients undergoing TECAB at 2 institutions by 4 surgeons, Objectives: We report our institutional experience with robotic-enhanced cardiac
between October 2001 and August 2010. Grafting strategies included 29 double surgery.
(28 left internal mammary (LIMA) to left anterior descending (LAD) and Methods: Patients undergoing robotic enhanced (n=16) cardiac surgery were
diagonal branch; 1 LIMA-obtuse marginal (OM) -OM or ramus) and 3 triple (2 prospectively included between February 2008 and October 2010. The
RIMA LAD, LIMA OM-OM or ramus; 1LIMA LAD, axillocoronary saphenous feasibility, safety and echocardiographic follow-up were evaluated.
vein graft ramus-OM1) vessel procedures. All operations were performed in
a completely endoscopic fashion through 4 or 5 ports using a surgical robot. Results: 16 patients with a median age of 48 years old (range 24-75) underwent
The internal mammary arteries were harvested using a skeletonized technique. robotic-enhanced cardiac surgery. All the patients were operated with the da Vinci
Cardiopulmonary bypass was provided via femoral cannulation and cardioplegic S robotic system. Procedures performed were mitral valve repair in 8 patients
arrest achieved with an endoaortic occlusion balloon. On-table post TECAB (50%), tricuspid valve repair in 2 patients (12.5%), atrial septal defect closure in
angiography was performed in 11 (34%) cases. TECAB was combined with 2 patients (12.5%) and single vessel (LIMA/LAD) TECABG (total endoscopic
a planned percutaneous intervention in 5 (15.6%) patients as part of a hybrid coronary artery bypass graft) in 4 patients (25%). No patient required conversion
revascularization strategy. to sternotomy. There was no operative mortality. Mean blood transfusion was
1.6 packages/patient. No neurological, vascular or wound complication was
www.mirasurgery.org 21
Oral Abstracts
observed. Mean CPB and aortic cross clamping were 140±28min and 118±25 Results: Twenty-two patients with uteri weighing in excess of 1000 grams
min respectively. TECABG patients were operated on beating heart and off pump. underwent hysterectomy with the robotic system. The mean age of the robotic
Mean ICU stay was 1.5±0.7 days. No patient required reoperation. Follow-up patients was 48 years (range 39–65 years) and 46 years in the laparotomy
ranged from 2-34 months, during which all of the patients remained with trace group (range 39–59 years). The mean BMI was 31.9 kg/m2 (range 18.5–56.3
of mitral valve regurgitation in all the mitral repair patients and mild tricuspid kg/m2) and the uterine weight was 1467 gms (range 1000-3563 gms) in the
valve regurgitation in all the tricuspid repair patients. All the atrial septal defect robotic group versus 30.9 kg/m2 (range 18–41 kg/m2) and 1478 gms (range
patients were successfully closed. Postoperatively all the coronary patients 1000-3570 gms) in the open surgery group. These results were not statistically
became completely asymptomatic and coronary angiogram or coronary computed significant. A significant difference was found for the following parameters: the
tomography, performed 2-6 months post-operatively, did demonstrate a very mean operating time was 255 minutes (range 180-338 minutes) for the robotic
nicely patent LIMA to LAD anastomose. surgery group vs 167 minutes (range xxx-xxx minutes) in the laparotomy
group (p=0.003). The mean blood loss recorded was 211 mL (100-1000 mL)
Conclusion: Mitral and tricuspid valve repair, ASD closure and single TECABG can
for robotic surgery vs 386 mL (150-800 mL) for open abdominal surgery
be safely performed, with excellent and durable results in a wide range of patients
(p=0.014). Eighteen / 22 (82%) robotic patients were discharged from the
in routine surgical settings. Low blood transfusion rate, short hospital stay and the
hospital on postoperative day 1. There were no conversions to laparotomy.
avoidance of wound complication are the main advantages of this approach.
The mean hospital stay for the robotic patients was 1.2 days and for laparotomy
S036: SENTINEL LYMPH NODE MAPPING IN PATIENTS WITH patients was 2.8 days (p=0.0001).
ENDOMETRIAL CANCER UNDERGOING ROBOTICALLY ASSISTED OR Conclusion: Robotic hysterectomy for very large myomatous uteri require longer
STANDARD LAPAROSCOPIC PROCEDURES Mario M Leitao, MD, Fady operative times but result in shorter hospital stay and decreased intraoperative
Khoury-Collado, MD, Ginger J Gardner, MD, Elizabeth Jewell, MD, Carol L blood loss.
Brown, Yukio Sonoda, MD, Douglas A Levine, MD, Richard R Barakat, MD,
Nadeem R Abu-Rustum, MD Memorial Sloan-Kettering Cancer Center S038: LEARNING CURVE FOR ROBOTIC HYSTERECTOMY: THE
HENRY FORD EXPERIENCE Mona E Orady, MD Department of Obstetrics,
Objective: To determine the feasibility of incorporating sentinel lymph node
Gynecology, and Women’s Health, Henry Ford Health System, Detroit,
(SLN) mapping into robotically assisted laparoscopic (RBT) and standard
Michigan
transperitoneal laparoscopic (LSC) procedures in patients with newly diagnosed
endometrial cancer. Objective: The objective of this study was to evaluate the magnitude and effect
of the learning curve on surgical outcomes of patients undergoing robotic
Methods: All cases with a preoperative endometrial cancer diagnosis that underwent
hysterectomy. Parameters that may affect the learning curve will also be assessed.
attempted SLN mapping during an RBT or LSC procedure without requiring
conversion to laparotomy from 9/25/05 to 8/25/10 were identified. Various Study Design: Retrospective cohort study.
clinicopathologic data were abstracted. Time to complete the SLN mapping was Setting: Henry Ford Health System’s community based teaching hospitals.
captured during RBT but not during LSC. Appropriate statistical tests were used.
Patients: 240 patients underwent Robotic Hysterectomy by one of 7 surgeons
Results: We identified 270 total cases (119 RBTs and 151 LSCs). SLN mapping between January 2007 and December 2010. Surgeons had each performed 5-84
was performed using only blue dye in 223 cases (83%). Isosulfan blue dye cases each with a median number of 29 cases per surgeon.
was used in 249 cases (92%). The site of dye injection was the cervix only in
248 cases (92%). SLNs were identified in 224 cases (83%). The nodal basin Interventions: Scheduled robotic assisted laparoscopic hysterectomy performed for
distribution of the identified SLNs was: right pelvis only (n=51; 23%), left benign indications.
pelvis only (n=32; 14%), bilateral pelvis (n=133; 59%), pelvis and aortic (n=6; Materials & Methods: All robotic hysterectomies performed for benign indications
3%), and aortic only (n=2; 1%). SLNs were identified in 136/151 (90%) LSCs by the 7 surgeons who were trained and began performing the procedure at
compared to 88/119 (74%) RBTs (P<0.001). SLN mapping in all RBT cases Henry Ford Health System Hospitals, from their first case until December 2010,
was done utilizing only cervical injections of blue dye. The median time to were identified. Case number, patient demographics, details of the operation,
perform SLN mapping robotically was 20 minutes (range, 5-65 min). Successful pathology, operative time (cut to close), and key outcome measures including
SLN identification was based on surgeon experience with SLN (P<0.001), estimated blood loss, length of hospital stay, and details of complications were
and the most experienced surgeon performed LSC exclusively. The nodal collected for analysis. Assessment of operative time versus case number for the 7
basin distribution of identified SLNs was similar for RBT and LSC (P=0.4). surgeons was performed and corrections for uterine weight and body mass index
The median BMI was 32.6 kg/m2 (range, 18.2-66) for the failed mapping (BMI) were made. Univariate statistical analyses as well as regression using
cases compared to 28.3 kg/m2 (range, 18.3-49.7) for the successfully mapped generalized estimating equations were then performed.
cases (P=0.003) irrespective of surgical approach. Identification of SLNs was
not associated with uterine weight, tumor histology, tumor grade, or use of Results: Analyses revealed that operative time decreases significantly for
preoperative lymphoscintigraphy. each surgeon as case number increases, up to approximately 40 cases, after
correcting for uterine weight (p=0.006). Factors that significantly influenced
Conclusions: SLN mapping is feasible, and can be easily incorporated into the operative time and the learning curve included whether a patient had a normal
management of patients with endometrial cancer undergoing both RBT and BMI (equal to 25 or less), whether a patient had a uterine weight > 250 grams,
LSC procedures. SLN mapping can be performed in a reasonable amount of and the expertise of the assisting surgeon (resident, fellow, or attending).
time. The use of preoperative planar lymphoscintigraphy does not appear to be Operative time decreases by half a minute, on average, with each sequential
necessary. Improvement in SLN identification, accuracy of SLN, and long-term case (SE=0.25, p=0.044). When BMI exceeds 25, cases take an average of 18
outcomes in this cohort of patients will require further study. minutes longer (SE=8.5, p=0.0338). When uterine weight is greater than 250
grams, cases take an average of 67.1 minutes longer (SE=9.6, p=<0.0001).
S037: A COMPARISON OF PERIOPERATIVE OUTCOMES BETWEEN It takes an average of 6.5 minutes longer per case, as compared to an expert
ROBOTIC AND OPEN HYSTERECTOMY FOR VERY ENLARGED UTERI assistant, when an attending is assisting, 13 minutes longer when a fellow
Fiona Lindo, MD, Taryn Gallo, MD, Masoud Azodi, MD, Dan-Arin Silasi, MD is assisting, and 19.5 minutes longer when a resident is assisting (SE=3.2,
Yale New Haven Health / Bridgeport Hospital p=0.041). In addition to decreasing operative time, a statistically significant
Study Objective: To examine the outcomes in patients with myomatous uteri difference in blood loss from early to late cases (p=0.009) was noted. In
weighing in excess of 1000 grams who underwent hysterectomy by two addition, there was a statistically significant decrease in length of stay from early
modalities: using the robotic system or by laparotomy. to late cases (p=0.0323). There was no significant difference in the incidence of
complications from early to late cases (p=0.516).
Methods: All patients who underwent robotic hysterectomy for uteri of at least
1000 grams at our institution from June 2007 to March 2010 were identified Conclusion: Operative time for robotic assisted total laparoscopic hysterectomy
and a retrospective chart review was performed. These patients were matched decreases as surgeon’s experience increase. The operative time and learning
to controls by body mass index (BMI) and uterine weight and the postoperative curve are significantly affected by the experience of the assistant surgeon,
outcomes in both groups were analyzed and compared. the uterine weight, and body mass index of the patient. Blood loss and

22 6 TH ANNUAL MIRA CONGRESS May 11-13, 2011


length of hospital stay for patients decrease as surgeon experience increases Conclusions: Robotic myomectomy can be performed adequately and safely and
but complication rates are stable throughout the learning curve. Overall, it has a much steeper learning curve in comparison to laparoscopy. Most of the
appears that patient safety is not compromised by the learning process for other parameters were comparable to conventional laparoscopy. Superiority of
performing robotic hysterectomy. robotic suturing in providing stability and strength in the uterus is to be proven
with long-term follow up studies.
S039: SAFETY AND EFFICACY OF ROBOTIC MYOMECTOMY Vasiliki
Chatzirafail, MD, Michael Litos, MD PhD MRCOG, Theodoros Mitsis, MD, S041: USE OF ROBOT IN HIGH ANORECTAL MALFORMATION
Nikolaos Bardis, MD, Aristidis Bakas, MD Eyroclinic,Athens, Greece Abdulrahman Albassam, MD, Abdulmonem Gado, MD, Mohammed Mallick,
MD Division of Pediatric Surgery, Department of Surgery, King Khalid
Introduction: The optimal surgical treatment for myomas remains debatable
University Hospital
because of the limitations of minimally invasive techniques and the disadvantages
of laparotomy. Robot-assisted myomectomy is a recently introduced technique. Introduction: Since 1980 posterior sagittal anorectoplasty for High Anorectal
The aim of this study is to evaluate outcomes of patients who underwent robotic Malformation (ARM) is the procedure of choice for most of Pediatric surgeons.
myomectomy. Laparoscopic-assisted anorectoplasty (LAARP) was introduced in 2000 by
Georgeson and is gaining popularity. Robotic surgery is an emerging field in
Methods & Procedures: Retrospective study of 46 patients undergoing robotic
minimally invasive surgery. To the best of our knowledge, no report has been
myomectomy. Data included indications, patients’ characteristics, fibroid
published that describes the use of robot in high ARM. The aim of this study is
characteristics (number, size, location), blood loss, intra operative and post
to report on our early experience in using robot in high ARM with emphasis on
operative complications, and hospitalization time.
feasibility, safety and early functional outcome.
Results: The average age was 41 years, and the average BMI 25,8. The indication
Materials & Methods: Children who underwent robotic-assisted repair of
for the myomectomy was bleeding in 12 cases, infertility in 22, pain in 4
high ARM between April 2006 and March 2010 at King Khalid University
cases and mixed symptoms in 8. A total of 81 fibroids were removed with
Hospital, Riyadh, Saudi Arabia using the Da Vinci surgical system is included.
an average of 1,9 per case. Looking at the largest fibroid for each case, the
The medical records were reviewed with respect to demographic data,
diameters ranged from 5 to 13 cm, with a mean of 7,6 cm and a median of
associated anomalies, techniques and operative procedure, complications,
8,5 cm. Summing up the diameters of all fibroids per case, the total diameter
outcome and follow-up.
ranged from 5 to 28 cm, with a mean of 10.6 cm and median of 9 cm. Of all the
fibroids, 37 were posterior, 20 anterior, 12 fundal, 8 in the broad ligament, and Results: A total of five male infants underwent robotic-assisted repair of high
4 were cervical. Most of them were intramural, with 5 being predominantly ARM. Age ranged from 4 to 11 months (mean 6.6 m). Body weight ranged
intramural-subserous and 13 intramural-submucous. A percentage of 95,8% from 6.2 to 9.9 kg. (Mean 7.6 kg). Three patients have associated anomalies.
of the operations were uneventful. One patient required laparotomy and blood All had colostomy at birth. Pre operative distal loopgram showed rectoprostatic
transfusion intraoperatively (2.1%), and one operation was converted to robotic fistula in 3 and rectobulbar in 2. Robotically assisted repair of high ARM was
total hysterectomy because the fibroid was paracervical and could not be done in all 5 patients utilizing Georgeson’s technique. The fistula was divided
exposed (2.1%). There was one case of post operative haematoma that resolved and ligated in 4 patients and was left open in one. Total operative time (robotic
conservatively (2,1%), and all uncomplicated cases were discharged the first post + anoplasty) ranged from 2.17-5.08 hours (M 3.56h). All procedures were
operative day. successfully completed without conversion to open technique. One patient
developed left sided epididymorochitis at 3 and 6 months post operatively. All
Conclusion: Myomectomy can be performed effectively and safely using the Da
patients had their colostomy closed . It was difficult to assess fecal continence
Vinci Robot even in cases of large and/or multiple fibroids. Time, cost and
in two patients. Two patients who were four years old have voluntary bowel
expertise are obvious limitations, and further studies are needed for safer
movements with no soiling. One patient three year of age has fecal soiling and
conclusions.
is using laxative/enema for constipation. With respect to anoplasty there were
S040: LAPAROSCOPIC VS ROBOTIC FIBROID RESECTION: no stenosis, In all of them the anus was in a good position, only one patient had
EXPERIENCE 2008-2010 Konstantinos P Mirillas, MD, Konstantinos P partial mucosal prolapsed. Follow-up ranged between 6-36 months (mean 12m).
Mirillas, MD, Petros C Hiridis, MD, Dimitris Bisbikis, MD, Savas C Hiridis, Conclusion: Robotically-assisted repair of high ARM is feasible and safe and offers
MD MSc, Perikles S Chrysocheris, MD, Konstantinos M Konstantinidis, MD a good alternative to the gold standard posterior sagittal anorectoplasty for repair
PhD FACS ATHENS MEDICAL CENTER of high ARM. Robotic approach has advantages over laparoscopic, that include
Objective: In this study we compared 169 cases of conventional laparoscopic superior vision, easier dissection in the narrow pelvis and secure closure of
fibroid removal with 24 cases performed by robotically assisted technique. This rectourethral fistula. Early results are encouraging. A larger number of patients
comparative elaborate study, examines several parameters including a) duration and a longer follow-up are needed to evaluate the outcome of this novel approach.
of surgery, b) size and number of fibroids removed, c) estimated blood loss,
S042: FEASIBILITY AND ONCOLOGIC SAFETY OF TRANSORAL
d) mode of suturing, e) hospitalization and patient recovery, f) post-surgical
ROBOTIC HYPOPHARYNGECTOMY Se-Heon Kim, MD PhD, Young Min
follow-up, pregnancy rate and outcome g) surgeon’s ergonomy.
Park, MD, Armando De Virgilio, MD Yonsei University College of Medicine
Materials & Methods: Retrospective study of 169 laparoscopic cases vs 24 robotic
Objectives: Conventional surgical approaches for hypopharyngeal carcinomas
cases all operated by the same surgeon. Suturing technique used was comparable
have a great risk for developing treatment-related morbidity. To minimize
and performed in the same surgical unit. Factors being compared in the study
this morbidity, hypopharyngectomy by transoral robotic surgery (TORS) was
were independently reviewed by the theater personnel and the surgical team.
performed, and the efficacy and feasibility of this procedure were evaluated.
Pathology reports were issued in every single case and were all negative.
Methods: TORS was performed using da Vinci Surgical Robot (Intuitive Surgical,
Results: Surgical duration is significantly greater in the initial steps of robotic
Inc., Sunnyvale, CA) in 18 patients with T1 or T2 pyriform sinus cancer and
surgery, however it falls dramatically within the first few cases (10), and
posterior pharyngeal wall cancer. FK retractor (Gyrus Medical Inc., Maple
generally robotics are recognized to have a much steeper learning curve in
Grove, MN) was used for transoral exposure of the lesion. A face-up 30-degree
comparison to laparoscopy. Size and number of fibroids removed were equal
endoscope was inserted through the oral cavity and two instrument arms were
between the two methods but required a higher (supraumbilical) access in some
located in both sides of the endoscope. Pyriform sinus was totally resected as a
robotic cases. Suturing technique used was the same but there was a tendency
cone-shape from the vallecular to apex region, and ipsilateral arytenoid cartilage
for a continuous suturing in robotics that may save time in the future. Estimated
was saved for function preservation. The aryepiglottic fold was resected
blood loss was not statistically different among the two methods. Hospitalization
medially. Laterally, the inner perichondrium of the thyroid cartilage was peeled
and patient recovery were equivalent but there was a tendency for less pain relief
off after perichondrium was incised horizontally to make sure of the safe margin
with robotics. Postsurgical follow-up and pregnancy rates were not statistically
of antero-lateral portion. The posterior margin is an inferior constrictor muscle
different but further studies and long-term follow-up is required. Finally
of the posterior pharyngeal wall. We evaluated the robotic set up time, robotic
robotic myomectomy is more ergonomic, for both the surgeon and is especially
operation time, blood loss, surgical margins, swallowing time, decannulation
comfortable when side-docking since this allows uterine manipulation.
time, and surgery related complications.
www.mirasurgery.org 23
Oral Abstracts
Results: Transoral robotic hypopharyngectomy was performed successfully in S044: VIRTUAL REALITY ROBOTIC SURGERY SIMULATOR: MIMIC®
all eighteen patients. The mean robotic operation time was 62.4 minutes, and DV-TRAINER, A TOOL FOR CERTIFICATION ? C Perrenot, MD, M Perez,
an average of 17.5 minutes was required for the setting of the robotic system. MD, N Tran, MD, J P Jehl, J Felblinger, MD PhD, J Hubert, MD Urology Dept
There was no significant perioperative complication in the cases. Swallowing & IADI, CHU Nancy-Brabois. Allée du Morvan, 54511 Vandoeuvre-Les-Nancy,
function returned to all patients within 8.3 days average. Decannulation was France
carried out within an average of 6.3 days after surgery. We can confirm the Introduction : Development of robotic surgery requires training and assessment
negative margins by frozen section. Average surgical margins are 7.5mm of specific skills. Training on animal model or in operating room is expensive
circumferentially. and exposes to medico-legal implications of the learning curve. Virtual reality
Conclusions: Transoral robotic hypopharyngectomy was feasible and ontologically simulators are an interesting alternative, already used in laparoscopy but still under
safe technique for the treatment of early hypopharyngeal cancer. development for robotic surgery. The aim of this study is to check the validity of
the Mimic® simulator as a tool for learning robotic surgery specific skills.
S043: IS UKA MORE ACCURATE WITH ROBOTIC ASSISTANCE?
Material & Methods: A prospective study was conducted from December 2009
Nicholas J Dunbar, MS, Andrew D Pearle, MD, Eduardo M Suero, MD, Sharon
to March 2010, using a robotic surgery simulator dV-Trainer (MIMIC®). 75
Horowitz, BS, Michael A Conditt, PhD, Scott A Banks, PhD University of
subjects (5 experts with more than 100 robotic cases, 6 confirmed robotic
Florida, Hospital for Special Surgery, MAKO Surgical Corp
surgeons with 10 to 40 robotic cases, 8 robotic beginners, 37 surgeons and
Introduction: Unicompartmental knee arthroplasty (UKA) is an increasingly residents, 19 nurses and medical students) were included. Five exercises
attractive and clinically successful treatment for individuals with isolated representative of robotic specific skills (camera moving, clutching, endowrist
medial compartment disease who demand high levels of function. A major manipulation, hand coordination and visual force feedback) were chosen. The
challenge with UKA is to place the components accurately so they are analysis was performed by two experts and based on quiz, on more than 1100
mechanically harmonious with the retained joint surfaces, ligaments and scores on the simulator and on videotaped similar exercises performed on an
capsule. Misalignment of UKA components compromises clinical outcomes actual Da Vinci S.
and implant longevity. Cobb et al. (JBJS-Br 2006) showed that robot-
Results: Face and content validity were considered as high by most of the subjects.
assisted placement of UKA components was more accurate than traditional
Yet, some limitations about rotation, fluidity and 3D-vision were reported
techniques, and subsequently that the clinical outcomes were improved.
by participants. Assessment of competence with the dV-Trainer was highly
Cobb’s method, however, employed rigid intraoperative stabilization of
reliable (correlation coefficient = 0.783). The simulator was able to significantly
the bones in a stereotactic frame, which is impractical for routine clinical
differentiate five levels of ability (ANOVA p<0.05). The assessment on dV-
use. Robotic systems have now advanced to include dynamic bone tracking
Trainer was overall relevant regarding concurrent validity (correlation coefficient
technologies so that rigid fixation is no longer required. The question is - Do
= 0,822). When studied separately, some criteria and exercises were medium
these robotic systems with dynamic bone tracking provide the same accuracy
relevant and need improvement before being included in a credentialing program.
advantages demonstrated with robotic systems with rigidly fixed bones?
Conclusion: The robotic surgery simulator dV-Trainer is a reliable and valid
Methods: We compared robot-assisted and traditionally instrumented UKA in six
support tool for certification. Further studies are needed to choose the
bilateral pairs of cadaver specimens. In all knees, a CT-based preoperative plan
more relevant among the 30 further developed exercises and to develop the
was performed to determine the ideal positions and orientations for the implant
fundamentals in robotic surgery.
components. Traditional manual instruments were utilized with a tissue-sparing
approach to implant one knee of each pair. A haptic robotic system acting as a S045: DEVELOPMENT OF A SEMI-AUTOMATED ROBOT-ASSISTED
virtual cutting guide was used to perform the robot-assisted UKA, again with a FLEXIBLE ENDOSCOPE N. van der Stap, BS, R. Reilink, MS, I.A.M.J.
tissue-sparing approach. Postoperative CT scans were obtained from all knees, Broeders, Prof dr, S. Misra, dr, S. Stramigioli, Prof dr ir MIRA, University of
and the 3D placement errors were quantified using 3D-to-3D registration of Twente; Meander Medical Center.
implant and bone models to the reconstructed CT volumes (Fig. 1).
Objective: The objective of this study is to develop a robot that can control
Results: The magnitude of femoral implant orientation errors were significantly commonly used commercially available colonoscopes in order to make steering
smaller for the robot-assisted implants compared to traditionally implanted easier. Colonoscopy takes a long time to master, mostly because of the difficult
components (4° vs 11°, p<0.001, Table 1), but the magnitude of femoral steering mechanism of colonoscopes(1). When the feasibility of a nationwide
placement errors did not reach significance (3mm vs. 5mm, p=0.056, Table 2). screening program was investigated in The Netherlands, one of the conclusions
Table 1. Implant Orientation Errors was that there was a lack of specialists(2). Additionally, one of the research
Flexion Varus Internal directions within the Natural Orifice Transluminal Endoscopic Surgery
(NOTES) research focuses on the use of flexible endoscopes to perform surgery
Manual Instruments 5.1° 5.8° 8.3° without scars. One of the main problems in this research is endoscope control.
Robot-Assisted 1.6° 3.1° 2.2° By making the steering of colonoscopes easier, a national screening program for
colorectal cancer and development of NOTES instruments may become more
Table 2. Implant Placement Errors feasible. We will do this by designing and testing an image processing algorithm
Anterior Medial Superior which steers the scope automatically, developing a prototype and testing this
prototype in a realistic environment.
Manual Instruments 3.1mm 2.8mm 3.3mm
Methods: An alternative way of controlling several commercially available
Robot-Assisted 2.9mm 1.2mm 1.7mm colonoscopes was developed. Input from trained medical specialists was
important in this development. A mechanical interface was developed such that
Discussion: Well-placed UKA implants can provide durable and excellent it can be fitted to the proximal end of commonly used flexible endoscopes. The
functional results, which is an increasingly attractive option for young and active mechanical interface can be controlled by means of several algorithms. Two
patients with severe compartmental osteoarthritis who wish not to have or to algorithms were explored in order to facilitate image-based scope control (3).
delay a total knee replacement. Previous studies have demonstrated significant The first one, the optical flow algorithm, uses subsequent images to determine
improvement in implant placement accuracy and clinical results with robot- the motion of the environment from the camera’s point of view and correct
assisted surgery using rigid bone fixation. This study demonstrates it is possible the endoscope in the right direction. The second one, the image intensity
to achieve significant accuracy improvements with robot-assisted techniques algorithm, first filters the image and then calculates the centroid (lumen center)
allowing free bone movement. Additional larger trials will be required to that resembles the darkest part of the image. These algorithms were tested in
determine if these differences are realized in clinical populations. a virtual environment and used to steer the endoscope autonomously. In the
current study, these algorithms will be tested in a more realistic environment
and implemented in a prototype. This prototype is equipped with innovative
controls for situations in which the algorithm may fail to find the correct
direction (e.g. flexure, large carcinoma).
24 6 TH ANNUAL MIRA CONGRESS May 11-13, 2011
Results: When compared, the image intensity algorithm turned out to be more Methods: A human interface is designed that connects to a motorized steering
accurate. Furthermore, the robotically steered endoscope performed better to unit attached to a flexible endoscope. The motorized unit was the result
the manual steering technique (it kept the lumen better centered in the image) of earlier research that facilitates this test setup[3]. This allows optimal
(3). A prototype containing an intuitive interface and automated steering for compatibility with the clinical situation since the colonoscope itself remains
commercially available colonoscopes was created. intact. The interface was developed such that endoscope tip steering and
advancement is permitted by one hand, in contrast to the current practice in
Conclusions: The feasibility of an automated steering algorithm for colonoscopy
which a minimum of two hands is needed, leaving the other hand available
was investigated and implemented. If the colonoscopy procedure becomes
for handling additional instruments (for example during polypectomy.)
easier to learn and perform, more specialists can be trained in shorter time.
The endoscopist and patient may remain in their usual position, with the
Automated steering may result in a feasible, cost-effective nationwide screening
endoscopist’s dominant hand now on the grip which is around the scope. The
program for colorectal cancer and can be used in NOTES instruments.
grip is 19 cm long and consists of two rigidly connected parts; the gripping
1.
Anderson, JC, et al. Factors predictive of difficult colonoscopy. 2001, part and a sensor housing part for the 3DOF orientation tracker (XSens
Gastrointestinal Endoscopy, Vol. 54, No.5, 558-562. Technologies) that was utilized to enable position controlled steering. The outer
Klink, Letter to the President of the Dutch Chamber of Deputies. Betreft
2. form of the easy to hold grip was inspired on a regular handlebar, whereas the
Standpunt darmkankerscreening, 2010, Ministry of health, www.minvws.nl. inner structure contains a cut-out space for the scope and ribs to allow scope
gripping.
Reilink, R, Stramigioli, S and Misra, S. Image-Based Flexible Endoscope
3.

Steering. 2010 , IEEE/RSJ International Conference on Intelligent Robots and Results: A grip was constructed that yields sufficient friction to facilitate scope
Systems, Taipei, 2339-2344. advancement when squeezed, but allows the scope to slide through upon
relaxation. Position controlled steering was enabled through a 3DOF orientation
S046: ADVANCED ROBOTIC MULTI-DISPLAY EDUCATIONAL SYSTEM tracker. Upon rolling the grip in axial direction, the horizontal direction of the
(ARMES), AN INNOVATIVE REAL-TIME AUDIOVISUAL MENTOR endoscope tip was controlled. Pitching the grip resulted in movement of the
DURING COMPLEX ROBOTIC SURGERY Yanghee Woo, MD, Kazutaka camera in vertical direction.
Obama, MD PhD, Tae-il Son, MD, Hyung Il Kim, MD, Woo Jin Hyung, MD Conclusions: A prototype hand held interface was designed to steer a colonoscope.
Phd Department of Surgery, Robot and Minimally Invasive Surgery Center at Input from experienced endoscopists and supporting teams was used in order to
Yonsei University College of Medicine, Seoul, Korea create a system that can easily be implemented in the clinic.
Introduction: Explosive scientific and technological advancements of the 21st 1.
Gezondheidsraad (2009) Bevolkingsonderzoek naar darmkanker. 13.
century are profoundly impacting surgical training world-wide. Videos,
simulators, and virtual reality modules are being integrated into training Anderson, J.C., et al., Factors predictive of difficult colonoscopy.
2.

programs with the expectation that these will minimize the cost to the patient. Gastrointestinal Endoscopy, 2001. 54(5): p. 558-562.
The purpose of our project, Advanced Robotic Multi-display Educational System Reilink, R., S. Stramigioli, and S. Misra, Image-Based Flexible Endoscope
3.

(ARMES) was to create an innovative real-time audiovisual mentoring system Steering. Proceedings IEEE/RSJ International Conference for Intelligent
using multi-input display, TileproTM to aid in the performance of advanced Robotic Systems (Taipei, Taiwan), 2010: p. 2399-2344.
robotic surgical procedures.
Technique: As the pilot operation, we selected robotic distal gastrectomy with S048: ROBIN HEART - FROM VIRTUAL TO REAL SURGEON TOOLS.
gastrojejunostomy and extended lymph node dissection for the treatment of Zbigniew Nawrat, MD, Pawel Kostka, PhD Foudation of Cardiac Suregry
gastric cancer. We established three-stages of ARMES development: 1) the Development
standardization of key operative steps; 2) the preparation of well edited short The Foundation of Cardiac Surgery Development (FCSD) realize project of
video clips for each of the previously determined steps using our extensive polish robot named Robin Heart (www.robinheart.pl) and mechatronic tools.
library of videos of over 350 high quality robotic gastrectomies; and 3) the New, semi-automatic tools are in the process of emerging- our Robin Heart Uni
integration of these video segments into the da Vinci Robot system using System. The Robin Heart Shell console is equipped with a consulting program
TileproTM. We identified 30 key segments of a radical gastrectomy with D2 that makes it possible to obtain all patients diagnostic information during the
lymph node dissection and created short video clips for ARMES. ARMES operation, as well as elements of operation planning on the screen. The virtual
was successfully implemented from the trocar placement to resection and operating theatre introduced in our laboratory allows surgeons to train some
anastomosis during a robotic gastric cancer surgery. elements of an operation, check the best placement of the ports in order to avoid
Conclusion: We describe a novel intraoperative real-time mentor, the Advanced internal collisions. Exhausted by 3-D visualisation, this system can be helpful in
Robotic Multi-display Educational System. A prospective clinical trial evaluating planning of a operation on a given patient.
the effectiveness of ARMES on training of surgeons in complex robotic The Robin Heart manipulator has very good and relatively large working space,
operations is planned. in which surgeon can select small subspace with very good isotropic kinematics’
properties for manipulating of objects with good position accuracy. System was
S047: DEVELOPMENT OF A USER INTERFACE FOR COLONOSCOPE verified both functionally and technically. Standard technical evaluation allowed
CONTROL N Kuperij, BSc, R Reilink, MSc, IAMJ Broeders, Prof Dr, MP to estimate the value of positioning resolution equal 0.1[mm]. The mile stone
Schwartz, Dr, S Stramigioli, Prof University of Twente, Department of of the project were an animal experiment, carried out in January 2009 (Robin
Technical Medicine, University of Twente, Enschede, The Netherlands Heart model 1,2,Vision) and May 2010 (Robin Heart mc 2). The operations
Introduction: The goal of this study is to enhance the colonoscopy procedure by were performed on pigs at the Centre of Experimental Medicine, the Silesian
improving the intuitiveness of flexible endoscope tip control. For this purpose a Medical University in Katowice. The goal of these experiments was to show
control interface was designed to aid the physician in performing more efficient the constructors the area of indispensable changes which will be introduced to
and effective colonoscopy which is used to diagnose colorectal cancer. Early worked out devices before study of technology of serial production and clinical
detection of colorectal cancer can improve the current survival rates of 50-60% initiating. Robin Heart system experiment carried out on pigs allowed to verify
to 80-90%[1]. However, screening programs require extensive clinical resources many aspects of very complex project and was the source of hints for future
and diagnostic tests. Colonoscopy is considered one of the most difficult types of development. As a conclusions from the experiment users (surgeons) have
flexible endoscopy procedures, yet it remains the most sensitive detection method expressed good opinion on the ergonomics and possibilities of controlling the
for colorectal cancer[2]. The advanced skills that are required to adequately steer robotic arms by means of the Robin Heart Shell console. The opportunities of
the endoscope call for more intuitive control. Besides simplifying and accelerating operating by means of the Robin Heart Uni System mechatronic tool are very
endoscope introduction, the greater cognitive reserve that is obtained during the promising, as it may be mounted on the robot’s arm or controlled manually.
procedure allows for fast and accurate diagnosis. Moreover, the lengthy learning The Robin Heart family of Polish robots has a chance of becoming a commonly
curve of clinicians performing colonoscopy may be reduced. Clinical ideas and used high-tech technical and tele-medical system facilitating the performance
demands were intended to strongly influence prototype design, allowing optimal of some parts of operations in minimally invasive, precise manner, safe for the
clinical compatibility. patient and the surgeon.
www.mirasurgery.org 25
Oral Abstracts
S049: ROBOT ASSISTED- VS. CONVENTIONAL LAPAROSCOPY: A Results: Primary treatment was brachytherapy in n=5 ptients, HIFU in n=4,
STUDY OF THE IMPACT OF HYSTERECTOMY TYPE AND UTERINE external beam radiation in n=5 and brachytherapy and cryotherapy in n=1. The
SIZE Gunjal Garg, Deslyn Hobson, Saima Ghazal, Ylbe Franco, Sonia Kim, S. functional status of patients preoperative was compromised. Preoperative, all
Gene L McNeeley, David C Kmak, Awoniyi Awonuga, Susan L Hendrix Wayne patients were impotent and exhibited significant irritative symptoms as well.
State University/ Detroit Medical center The median age of the patients was 65 years (57-73), median BMI 28.8 kg/m2
(28-37 kg/m2) and median prostate weight 42.1 gr. (23-92 gr.). The median
Objective: To comparatively analyze the outcomes associated with supra-cervical
PSA value was 6.8 ng/ml (1.7-16 ng/ml). The median operative time was 168
hysterectomy and total hysterectomy, performed via robot assisted- versus
min (120-220 min) and estimated blood loss was 151ml (20-350 ml). No major
conventional laparoscopy at our institution.
complications were noted and minor complications were evident only in N=2
Methods: Data were collected on all patients that underwent either a cases (13.3%) (urine leak identified by postoperative cystogram). The length of
laparoscopic or robotic hysterectomy between 2003 and 2010. Statistical catheterization was 6.5 days (5-13 days). An organ-confined disease was noted
analysis used t-test, Pearson’s Chi-square test, and multiple regression analysis in N=6 (40%) patients and extraprostatic extension in N=9 (60%). The median
in a forward stepwise method. percentage of CaP found in the prostate specimen was 27.1% (2%-84%),
Results: A total of 699 patients were included; 574 supra-cervical hysterectomy positive surgical margins were noted in N=1 case (6.6%) and positive lymph
(524 laparoscopic and 50 robotic) and 125 total hysterectomy (48 laparoscopic and nodes in N=1 case (6.6%) as well. After a median follow up of 20.2 months (6-
77 robotic). There were no significant differences between the robotic and the 53 months) 40% were continent (0 Pads/d) and 46.7% mild incontinence (1-2
laparoscopic groups with regards to patient age, race, body mass index, number Pads/d). 66.6% were free of biochemical progression.
of previous laparotomies, or primary pain control method, for both hysterectomy Conclusions: Our findings suggest that salvage RALP is a safe and effective
types. Although, the mean operative times were comparable between the therapeutic modality in patients with locally recurrent prostate cancer. Although
robotic total hysterectomy and the laparoscopic total hysterectomy (168 vs. 183 surgical and oncologic outcomes are satisfying, patients should be made aware of
minutes, p>0.05); it was significantly shorter for the laparoscopic supra-cervical suboptimal functional outcomes before undergoing the procedure.
hysterectomy compared to the robotic supra-cervical hysterectomy (133 vs. 188
minutes, p <0.001). The estimated blood loss did not differ significantly between S051: ONCOLOGICAL OUTCOMES OF ROBOTIC GASTRECTOMY FOR
the robotic supra-cervical hysterectomy and the laparoscopic supra-cervical GASTRIC CANCER COMPARED TO LAPAROSCOPIC GASTRECTOMY
hysterectomy (130 vs. 143 ml, p=0.6); although, it was significantly less for the Kazutaka Obama, MD, Woo Jin Hyung, MD PhD, Yanghee Woo, MD, Hyoung-
robotic total hysterectomy compared to the laparoscopic total hysterectomy (92 Il Kim, Sung Hoon Noh, MD PhD Yonsei University College of Medicine
vs. 171 ml, p<0.001). Pain score on the day of surgery was significantly higher Introduction: Robotic gastrectomy for gastric cancer has not widely accepted
in the robotic group compared with the laparoscopic group for both supra- yet, even though there are some reports that showed its feasibility and safety.
cervical hysterectomy (5.1 vs. 3.0, p<0.001) and total hysterectomy (5.4 vs. 3.0, The oncologic safety of robotic gastrectomy for gastric cancer still remains a
p<0.001). There was no significant difference with regards to the complication concern. There is no report of long-term outcome of robotic gastrectomy for
rate (intra-operative, immediate- and/or delayed post-operative) between the gastric cancer. We aimed to assess the oncologic safety of robotic gastrectomy by
robotic and the laparoscopic groups in patients undergoing either a supra-cervical evaluating its long-term outcomes (survival and recurrence) with comparison to
hysterectomy or a total hysterectomy (p>0.05). Upon stratification of the surgical conventional laparoscopic gastrectomy.
outcome data by uterine weight (<250 g or ≥ 250 g); the above mentioned trends
regarding laparoscopic versus robotic procedure were maintained in each uterine Patients & Methods: For retrospective cohort analyses, using a prospectively
weight category for both hysterectomy types. On a subsequent multiple regression collected database for gastric cancer the in Yonsei University Severance
analysis, procedure type (laparoscopic versus robotic) was found to be an Hospital, we extracted 316 robotic and 538 laparoscopic gastrectomies
independent predictor of operative time in supra-cervical hysterectomy(favoring performed for gastric cancer patients from July 2005 to December 2009. After
laparoscopic), estimated blood loss in total hysterectomy(favoring robotic), and excluding operative mortality and combined operations for other cancers,
pain on day of surgery in both supra-cervical and total hysterectomy (favoring patients who had undergone 313 robotic and 524 laparoscopic gastrectomies
laparoscopic), after controlling for other confounding factors such as age, race, were compared in terms of recurrence, patterns of recurrence, and survival.
body mass index, previous laparotomies, uterine weight, operator experience, and Results: Robotic gastrectomy group (RG) showed younger and more advanced disease
primary method of pain control (epidural vs. patient controlled analgesia). than laparoscopic gastrectomy group (LG). With a median follow-up period of 36
Conclusion: Although, robotic surgery was associated with reduced blood loss months, recurrence was 5.1% (16/313) in RG and 2.9% (15/520) in LG (p=0.100).
in total hysterectomy; it did not seem to confer any advantage in supra-cervical There was no difference in recurrence pattern in both groups. The 5-yr overall
hysterectomy, regardless of the uterine weight. Additionally, it was associated survival rate of RG was 94.9% in the RG group and 93.8% in the LG and the hazard
with significantly higher pain scores than the laparoscopic procedure for both ratio for death in the RG as compared to the LG was 0.87 (95% confidence interval,
supra-cervical and total hysterectomy. 0.43 to 1.78; P=0.702). The 5-yr relapse free survival rate of RG was 93.1% in the
RG group and 92.2% in the LG. When we compared the survival after stratifying by
S050: ROBOTIC-ASSISTED SALVAGE PROSTATECTOMY. SURGICAL, stages, survivals of both groups were similar in each stage.
ONCOLOGIC AND FUNCTIONAL OUTCOMES Apostolos P Labanaris, MD Conclusions: This large-sized study showed that robotic gastrectomy for gastric
PhD, Vahudin Zugor, MD PhD, Jorn H Witt, MD PhD Department of Urology cancer had acceptable long-term oncologic outcomes compared to laparoscopic
and Pediatric Urology - Prostate Center Northwest, St. Antonius Medical gastrectomy, although this is a single center study. The study provides
Center, Gronau, Germany additional evidence suggesting that robotic gastrectomy is a good alternative
Introduction: During the past years robot-assisted laparoscopic radical for laparoscopic gastrectomy in patients with gastric cancer, although results
prostatectomy (RALP) has become profoundly popular and with the expanding of a multicenter prospective study and more long-term follow-up are needed to
experience obtained with it the selection criteria for the procedure have also provide conclusive evidence.
widened and included more challenging cases. The objective of this study is to
assess the surgical, oncologic and functional outcomes in patients undergoing S052: MULTIDIMENSIONAL ANALYSES OF THE LEARNING CURVE OF
salvage RALP. ROBOTIC GASTRECTOMY FOR GASTRIC CANCER: A COMPARISON
WITH LAPAROSCOPIC GASTRECTOMY Hyoung-Il Kim, MD, Woo Jin
Methods & Procedures: The records of N=2000 men who underwent RALP Hyung, MD, Yanghee Woo, MD, Kazutaka Obama, MD, Sung Hoon Noh, MD
at a certified robotic institute from February 2006 to April 2010 were Department of Surgery, Institute of Gastroenterology, and Cancer Metastasis
retrospectively reviewed. A total of N=15 patients were identified as having Research Center Yonsei University College of Medicine, Seoul, Korea
undergone salvage RALP. The parameters analyzed included: age, body-mass
index (BMI), prostate weight, PSA values, percentage of prostate cancer (PCa) Introduction: Robotic surgery for gastric cancer showed excellent clinical
found in the prostate specimen, skin-to-skin operative time, estimated blood results and it has been increasing. However, the learning curve of the robotic
loss, minor (Clavien’s grade I–IIIa) and major complications (Clavien’s grade gastrectomy has not yet been evaluated. The aim of this study was to assess
IIIb-IVa), length of catheterisation, pathologic stage, lymph node status, positive the learning curves of robotic gastrectomy using multidimensional analyses in
margin status, and continence (defined as no pad use). comparison with that of laparoscopic gastrectomy.
26 6 TH ANNUAL MIRA CONGRESS May 11-13, 2011
Methods & Procedures: From May 2003 to April 2009, 883 consecutive minimally Objectives: Robotic thyroidectomy has several advantages over conventional
invasive gastrectomies were performed. Excluding total gastrectomies and endoscopic thyroid surgery. However, few studies have compared the robotic
combined resections, 172 robotic and 481 laparoscopic distal gastrectomies and pure endoscopic thyroidectomy techniques in terms of postoperative
were analyzed. The operation time was evaluated using moving average and non- outcomes. Moreover, such an operative approach may cause musculoskeletal
linear regression model. The success of surgery was analyzed by cumulative sum discomfort in the surgeon, which may in turn impact patient outcome. The aim
(CUSUM) plot. The failure of surgery was defined as open conversion, lymph of this multicenter study was to confirm the merits of robotic thyroidectomy by
nodes harvest less than 16, and perioperative morbidity and mortality. The comparing endoscopic thyroidectomy in patients with thyroid carcinomas, and
target failure rate was 0.1. to compare physician perspectives on the musculoskeletal ergonomic parameters
associated with open, endoscopic, and robotic thyroidectomy.
Results: For each robotic and laparoscopic gastrectomy group, moving average
graph indicated steady state at 95 and 270 cases respectively; non-linear Materials & Methods: Between November 2001 and June 2010, a total of 2,612
regression model indicated no definite steady state and at 267 cases respectively; patients with thyroid carcinomas underwent at three centers by four surgeons.
adjusted non-linear regression model indicated at 121 and 262 cases respectively. Of these patients, 1,769 patients underwent robotic thyroidectomy (robotic
The adjusted factors were age, sex, body mass index, reconstruction method and group), and 843 patients a conventional endoscopic thyroidectomy (endoscopic
extent of lymph node dissection. The CUSUM plot showed no cut-off point in group). These two groups were retrospectively compared with respect to patient
robotic gastrectomy whereas at 80 cases in laparoscopic gastrectomy. characteristics, operative outcomes, complications, and pathologic results.
Moreover, surgeons were surveyed to gather data on musculoskeletal discomfort
Conclusion: The multidimensional analyses of learning curve of robotic
experienced during open, pure endoscopic, and robotic thyroidectomy.
gastrectomy showed that an experienced laparoscopic surgeon requires fewer
cases numbers to reach steady state and successful surgical outcome is achievable Results: The patient demographics were similar in both groups. A total of 856
from the initial period compared with his laparoscopic gastrectomy. (32.8%) total thyroidectomy and 1274 (67.2%) less-than total thyroidectomy
were carried out. Total thyroidectomy was performed more frequently
S053: COMPARISON OF ROBOTICALLY ASSISTED AND STANDARD in the robotic group (p=0.004). The groups were comparable in tumor
LAPAROSCOPIC PROCEDURES IN PATIENTS WITH ENDOMETRIAL size, pathology, multiplicity, and bilaterality. However, tumor stage in the
CANCER Mario M Leitao, MD, Ginger J Gardner, MD, Gabriel Briscoe, Kevin robotic group were more advanced than in the endoscopic group (p=0.002).
Santos, Elizabeth Jewell, MD, Nadeem R Abu-Rustum, MD, Carol L Brown, Statistically significant differences were noted in favor of robotic vs. endoscopic
MD, Dennis S Chi, MD, Yukio Sonoda, MD, Richard R Barakat, MD Memorial total thyroidectomy with regard to operative times (p<0.001). The total
Sloan-Kettering Cancer Center number of retrieved central lymph nodes was greater in the robotic group
Objective: To compare outcomes between robotically assisted laparoscopic (RBT) (p=0.012). The two groups showed no significant differences in terms of
and standard transperitoneal laparoscopic (LSC) procedures in patients with intra-operative and postoperative complications. When surgeons ranked the
endometrial cancer. operative approaches in decreasing order of associated pain, 57.1% indicated
endoscopic>open>robotic, 28.6% selected open>endoscopic>robotic, and
Methods: All cases with a preoperative endometrial cancer diagnosis scheduled 14.3% responded endoscopic>robotic>open.
for RBT among 9 surgeons were prospectively captured from 5/1/07-6/19/10.
A consecutive cohort of cases scheduled for LSC for endometrial cancer during Conclusion: Robotic thyroidectomy using gasless transaxillary approach was a
the same time period among 7 surgeons were retrospectively identified. All feasible, safe procedure and provided good outcomes for differentiated thyroid
surgeons were experienced LSC surgeons. Fellow involvement was gradually carcinoma patients. Moreover, for surgeons, the robotic approach resulted in
increased for the RBT group over time. Fellow involvement was constant in the less musculoskeletal discomfort than did open or endoscopic thyroidectomy.
LSC group. Operating room time (ORT) was measured from patient arrival in The present study also showed that robot technology overcame some technical
the OR to exit. Operative time (OT) was measured from skin incision to full limitations associated with conventional endoscopic procedures in terms of
closure. Appropriate statistical tests were used. operation time, and lymph node retrieval.

Results: We identified 271 cases planned for RBT and 278 planned for LSC. Median S055: ROBOT AND LAPAROSCOPIC ASSISTED GASTRECTOMY : A
BMI was 28.6 kg/m2 (range, 18.6-66) and 28.2 kg/m2 (range, 16.9-57.2), COMPARISON OF SURGICAL OUTCOMES Byunghee Kang MD, Junyoung
respectively. Conversion to laparotomy was necessary in 32 RBTs (12%) and 34 Kim MD, Sanguk Han MD, Department of Surgery, Ajou University, School of
LSCs (12%) (P=0.9). Pelvic and para-aortic lymphadenectomy was performed in Medicine, Korea
110/239 (46%) completed RBTs and 112/244 (46%) completed LSCs (P=0.8).
Introduction: Laparoscopic assisted gastrectomy(LAG) was widely accepted
Median ORT was 301 min (range, 142-613) and 253.5 min (range, 133-532),
operation technique in early gastric cancer. Recently, Robot assisted
respectively (P<0.001). Median OT was 217 min (range, 99-533) and 184.5 min
gastrectomy(RAG) has been accepted as an alternative minimal invasive surgery.
(range, 80-445), respectively (P<0.001). ORT and OT for RBTs varied among
This study aimed to evaluate the question whether RAG for treatment of gastric
surgeons; more experienced RBT surgeons had significantly shorter ORTs. After 40
cancer is feasible and safe.
cases per surgeon, the median times for RBT equaled those for LSC. Median pelvic,
paraaortic, and total nodal counts for RBTs were 14 (range, 3-34), 6 (range, 0-22), Method & Procedure: We prospectively collected data and retrospectively reviewed
and 21 (range, 7-48) compared to 16 (range 3-48), 5 (range 1-21), and 22.5 (6-57) 332 consecutive patients from Nov. 2008 to Dec. 2010. Laparoscopic or
for LSCs (P=NS for all). Median length of hospital stay (LOS) was 1 day (range, 1-5) robot assisted gastrectomy were performed by one attending surgeon at the
for RBTs (71% discharged on Postop Day 1), and 2 days (range, 1-15) for LSCs (27% Ajou University Medical Center. We compared clinicopathological features,
discharged on Postop Day 1 [P<0.001]). Median estimated blood loss for RBTs was operation time, and surgical outcome between the two procedures.
50 ml (range, 0-400), and 100 ml (range, 0-900) for LSCs (P<0.001). Result: 243 patients underwent LAG and 89 patients underwent RAG. 213
Conclusions: RBT and LSC approaches are both feasible, and both result in good patients of LAG underwent distal subtotal gastrectomy and 30 patients
outcomes in patients with endometrial cancer. RBT was associated with longer underwent total gastrectomy. 78 patients of RAG underwent distal subtotal
ORT and OT compared to LSC in a well-established and experienced LSC gastrectomy and 11 patients underwent total gastrectomy. RAG patients were
program. However, ORT and OT were equal after 40 RBT cases per surgeon. younger than LAG (52.97 ± 12.1 vs 58.72 ± 12.0, p<0.001). Operation time
Patients who underwent an RBT had a shorter LOS. LOS may be related to was longer in RAG (203.82 ± 53.1 vs 171.65 ± 51.38, p<0.001). Postop
surgeon preferences and initial clinical pathways. morbidity cases(14.6% in RAG vs 9.9% in LAG, p=0.225) were not significant
difference. In subtotal gastrectomy cases, more lymph nodes were harvested
S054: MULTICENTER STUDY OF ROBOTIC VERSUS ENDOSCOPIC in RAG (38.27 ± 16.1 vs 34.24 ± 11.9, p=0.021). But there is no significant
THYROIDECTOMY FOR THYROID CANCERS: POSTOPERATIVE difference in total gastrectomy cases.
OUTCOMES AND SURGEON ERGONOMIC CONSIDERATIONS Hee-Lee-
Conclusion: RAG is a safe as well as a feasible procedure, providing a satisfactory
Nah Suh, MD, Jandee Lee, MD, Sang Wook Kang, MD, Jeoung Ju Jung, MD,
postoperative outcome.
Un Chung Choi, MD, Jong Ho Yun, MD, Woong Youn Chung, MD PhD Ajou
University School of Medicine1, Yonsei University College of Medicine2,Won-
Kwang University College of Medicine3, Ulsan University School of Medicine
www.mirasurgery.org 27
Video Abstracts
V001: ROBOTIC-ASSISTED RESECTION OF ESOPHAGEAL LEIOMYOMA Center Utrecht (The Netherlands) patients with resectable esophageal
Koji Park, MD, Syed Razi, MD, Jordan Sasson, MD, Cliff P Connery, MD, cancer undergo robot assisted thoracolaparoscopic esophagectomy. Extensive
George J Todd, MD, Scott J Belsley, MD, Faiz Y Bhora, MD St. Luke’s- experience with this procedure has been gained since 2003.
Roosevelt Hospital Center The presented case concerns a 48 year old male patient with an ultrasound
Introduction: Esophageal leiomyoma is a rare benign esophageal tumor, accounting confirmed T3N1 adenocarcinoma of the distal esophagus. The indicated
for <1% of all esophageal tumors. Leiomyomas are generally asymptomatic until procedure for this patient is a robot assisted thoracolaparoscopic esophagectomy
they are >5cm in size. Larger esophageal leiomyomas are typically associated with with a 2-field lymphadenectomy. The procedure is marked by three distinct
symptoms related to mass-effect, most often dysphagia. Recommended treatment phases; 1) esophageal mobilization and mediastinal lymphadenectomy by robot
of these larger, symptomatic lesions is surgical excision. Traditionally, leiomyomas assisted thoracoscopy, 2) gastric mobilization and truncal lymphadenectomy by
are excised via open thoracotomy. However, minimally invasive techniques via conventional laparoscopy, 3) esophageal dissection through cervicotomy and
thoracoscopy have been described recently. We propose that a robotic-assisted reconstruction with a gastric conduit.
approach is a safe and feasible method of excising large esophageal leiomyomas. The presented video focuses on the robot assisted thoracoscopic part of this
Methods & Procedures: After induction of general endotracheal anesthesia, the procedure showing esophageal mobilization and mediastinal lymphadenectomy.
patient was turned in the left lateral decubitus position. An endoscope was easily The DaVinci Si robotic system is used for improved surgical control and vision
passed through the esophagus into the stomach. Upon entry into the chest, the within the surgically challenging environment of the thorax and mediastinum.
large esophageal mass was seen adjacent to the azygos vein and superior vena The application of the robot in this procedure enables a precise and extensive
cava. The da Vinci Robot was then introduced and the mediastinal pleura was lymphadenectomy and maximizes chances of oncological clearance.
opened with cautery. The thin, overlying muscle layer was divided and the One camera port and two instrumental ports are placed. The operating surgeon
avascular plane between the esophageal muscularis and the mass was dissected is assisted by an assisting surgeon through two additional ports, mainly used
circumferentially, with great care taken not to violate the mucosa. The mass for suctioning and application of hemoclips. To enhance vision of the operative
was placed in a specimen bag and removed. An air leak test was performed field, single lung ventilation is applied and the esophagus is manipulated with
with the esophagus submerged under saline irrigation. Intraoperaive endoscopy the use of a penrose drain. Thoracoscopic mobilization of the esophagus
confirmed no evidence of leak. The esophageal muscle layer and pleura were and surrounding tissue is followed by conventional laparoscopy for gastric
closed in order to prevent pseudodiverticulization of the mucosa. mobilization and truncal lymphadenectomy. After laparoscopy, the proximal
Results: Total operative time was 3 hours and 3 minutes. Blood loss was minimal. esophagus is dissected through a left-sided cervicotomy. The gastric conduit is
There were no intraoperative or postoperative complications. A postoperative formed extracorporally with the use of GIA stapling and is routinely oversewn
swallow study demonstrated no evidence of leak. The patient’s chest tube was to prevent leakage. The procedure is then completed with a handsewn end-to-
removed on the first postoperative day, and the patient was discharged home on side esophagogastrostomy and removal of excess gastric tubing. Postoperative
the second postoperative day. Pathology confirmed the presumptive diagnosis of intake is ensured with a feeding jejunostomy.
leiomyoma. Postoperative recovery was uneventful and the patient was discharged from the
Conclusions: The superior ergonomics and three-dimensional visualization hospital ten days after surgery. Forty days later the feeding jejunostomy was
associated with the da Vinci robot facilitates the safe dissection of a large bulky removed in the outpatient clinic after full recovery of oral intake.
tumor from the esophagus, minimizing the risk of injury to adjacent vascular
structures and to the esophageal mass. This case demonstrates the feasibility and V004: ROBOTICS MAY SAVE THE DAY WITH GANGRENOUS
safety of the robotic-assisted resection of large esophageal leiomyomas. CHOLECYSTITIS: A NOT SO USELESS OPERATION AFTER ALL
Konstantinos M Konstantinidis, MD PhD FACS, Savas C Hiridis, Periklis S
V002: ROBOTIC SINGLE PORT RIGHT HEMICOLECTOMY IN AN OBESE Chrysocheris, Michael K Georgiou, MD ATHENS MEDICAL CENTER
PATIENT Vincent Obias, MD, Rami Makhoul, MD, Sam Damle, MD, Grace Introduction: Many studies support that conversion performed for minimally
Montenegro, MD George Washington University invasive cholecystectomy is a proof of professional responsibility; gangrenous
Purpose: To demonstrate a robotic right hemicolectomy in an obese patient, acute cholecystitis is one of the most important causes of conversion. Robotics
demonstrate the steps associated with a single port robotic right hemicolectomy, overcome certain limitations of laparoscopic surgery with superior visualization
and provide technical tips on robotic single port surgery of the field and dexterous wristed instruments. Robotic cholecystectomy is
considered as a good start for the learning curve of a new robotic surgical team.
Methods: The patient was placed in supine position. One inch incision made in
skin and fascia. A Covidien SILS port used. Laparoscopic single incision surgery Aim: To present our experience with robotic cholecystectomy in difficult cases.
was done to explore the abdomen and identify structures. The robot was then Methods: We present 83 robotic cholecystectomies performed by our team
docked using a two working arm technique with the robotic arms crossed at since September 2006. In 14 of these cases, a challenging advanced gangrenous
the fascia level. Once the robot was docked, the robotic arm designation on state of the gallbladder was managed robotically without complications or any
the console was switched so that the left arm on the screen is now controlled considerations for conversion.
by the left hand in the console and the right arm on the screen is controlled
by the right hand. We next did a standard right hemicolectomy by ligating the Results: All patients followed an uneventful recovery including those with the
ileocolic artery, dissecting medial to lateral separating the right and transverse gangrenous cholecystitis. There were no conversions, neither serious morbidity
colon mesentary from the retroperitoneum, mobilized the right colon and and no mortality. Recognition of the critical view during initial dissection was
proximal transverse colon, exteriorized the right colon, transecting it, and then greatly facilitated by the robot, especially in complicated cases with abundant
performing an ileocolic anastamosis. adhesions. The operation was not affected by the patient’s BMI.
Results: Operative time was 180 minutes. Length of stay was 4 days. No post Conclusions: Robotic cholecystectomy is a safe operation. Robotics may save the
operative complications noted. The surgeon noted improved ergonomics, better day in difficult cases of distorted anatomy and diffuse inflammation and should be
tissue manipulation and a greatly improved view due to the high definition 3D considered as an alternative to conventional laparoscopy if the system is available.
view and the stable camera platform.
V005: ROBOTIC DISTAL PANCREATECTOMY: OUR TECHNIQUE.
Conclusion: Robotic single port surgery is a viable alternative to traditional single Konstantinos M Konstantinidis, MD PhD FACS, Savas C Hiridis, MD MSc,
port laparoscopy and has some advantages over laparoscopic single port surgery. Michael K Georgiou, Perikles S Chrysocheris, MD aFACS Athens Medical Center
V003: ROBOT-ASSISTED THORACOSCOPIC ESOPHAGECTOMY AND Introduction: Tumors of pancreatic tail can be resected laparoscopically with
LYMPHADENECTOMY RJJ Verhage, MD, PC van der Sluis, MD, R van good results. Robotics may offer a more stable platform for dissection and
Hillegersberg, MD PhD University Medical Center Utrecht, the Netherlands mobilization of such tumors especially when the spleen should be preserved.
Thoracoscopic esophagectomy was introduced to reduce the morbidity of Aim: We present the technique used by our team for robotic removal of
conventional open transthoracic esophagectomy. In the University Medical pancreatic tail masses with or without splenic preservation.

28 6 TH ANNUAL MIRA CONGRESS May 11-13, 2011


Methods: A robotically - assisted distal pancreatectomy with splenectomy was V009: ROBOTIC HYSTERECTOMY FOR STAGE IV ENDOMETRIOSIS Dan-
performed in 7 cases. Spleen preservation was performed in 2 cases succesfully. Arin Silasi, MD, Taryn Gallo, MD Yale New Haven Health / Bridgeport Hospital
The da Vinci system greatly facilitated dissection around the pancreatic tail, Case presentation: Our patient is a 45 year old female with a long-standing
mobilization of the stomach and omentum and dissection in the splenic hilum. history of significant pelvic pain. She has a surgical history of three prior
The specimens were extracted in an endobag. In 2 cases an extension of the cesarean sections. Preoperative ultrasound shows a complex adnexal mass. Our
left lateral incision was made and an extracorporeal division of the pancreas video demonstrates our experience with robotic hysterectomy for a Stage IV
performed. In the rest of cases, division of the pancreatic tail was performed endometriosis with a frozen pelvis.
endoscopically using an endostapler.
Results: There was no blood loss, nor any need for transfusion, while operation V010: ROBOTIC RADICAL HYSTERECTOMY FOR VAGINAL SARCOMA
time was comparable to laparoscopy. The patients had an uneventful recovery and Eugene P Toy, MD, Julietta Fiscella, MD University of Rochester
left the hospital on the 5th postoperative day. A minor leak from the drain was The patient is a 48 year old female who had undergone vaginal resection of an
noticed in two of the patients but gradually subsided with conservative measures. angiomyofibroblastoma 5 years earlier and now is found to have a recurrent vaginal
Conclusions: Robotically-assisted distal pancreatectomy is a valid treatment option tumor noted on workup for abnormal bleeding. Review of her prior pathology
for pancreatic tail tumors especially when preservation of spleen is attempted. showed a differential of epithelioid leiomyoma in addition to angiofibroblastoma. A
simple vaginal excision had been performed in 2005 with no adjuvant therapy given.
V006: KIDS SAY THE DARNDEST THINGS...AND WHAT THEY EAT IS Her current MRI from December 2009 revealed a recurrent mass arising in the right
PRETTY WEIRD TOO John J Meehan Seattle Children’s Hospital, University paravaginal area measuring 5.4 X 4.4 cm. Physical exam confirmed the proximal
of Washington right vaginal mass with either mucosal involvement or scarring noted after her prior
resection. No other evidence of adenopathy or uterine pathology was seen.
Of the nearly 50 diffferent types of robotic procedures we have performed in
children, this one has to be the most unusual...but also the most memorable. She subsequently underwent a DaVinci robotic assisted laparoscopic radical
Foreign body ingestion is a common problem amongst toddlers and small hysterectomy with en bloc resection of the paravaginal mass. The radical
children. The cricopharyngeus is the most narrow region of the GI tract and resection was necessary to resect the mass in continuity with the uterus, cervix,
any solid objects that pass this region have a high likihood of continuing without parametria, and upper vagina. Console time was 3 hrs and 50 minutes with
incidence. However, that did not happen in the case we are presenting here. In estimated blood loss of 100 ml. The patient was discharged home on post-
fact, we are still surprised that this thing ever made it past the cricopharyngeus. operative day one. The intraoperative pathology was reported as an epithelioid
We offer a video presentation of an unusal application of the da Vinci surgical angiosarcoma. Final pathology was revised to malignant mesenchymal neoplasm
robot in a 5 year old child who swallowed a large smooth object that somehow arising in the posterior paravaginal sac. Closest margin was within 5 mm, and
passed the cricopharyngeus but would not pass the pylorus. Although we will she received adjuvant radiation and chemotherapy.
leave the identity of the object a mystery until the video is seen at the meeting
(an amusing but minor detail to the case itself), the size of the object was the V011: ROBOTIC HYSTERECTOMY: APPROACH TO THE BULKY FIBROID
most striking issue in this case. An endoscopic attempt at retrieval using a UTERUS Mona Orady, MD Division of Minimally Invasive Gynecology and
flexible endoscope and basket failed as the object was too big to be brought back Robotic Surgery, Department of Obstetrics, Gynecology, and Women’s Health,
up the esophagus despite numerous efforts (what goes down doesn’t always Henry Ford Health System, Detroit, MI, USA
come back up). The da Vinci Surgical robot was used to create a gstrotomy The benefits of minimally invasive methods of hysterectomy are well described.
and retrieve the object rock from the stomach, and bring it out through an Minimally invasive hysterectomy offers patients smaller incisions, decreased blood
abdominal incision. This is an unusal application of the robot but demonstrates loss, decreased length of stay, and a faster recovery and return to normal activities.
the versatility of this technology. Since a picture is worth a thousand words, and Since the FDA approval of the daVinci Surgical System for use in Gynecology in
a movie is probably worth a book, we’ll let the video speak for itself . April 2005, robotic hysterectomy has helped to extend the ability of surgeons to
perform hysterectomy in patients who may not otherwise have been candidates for
V007: ROBOTIC TRACHELECTOMY Vasilis Kapetanakis, MD, Paul M a minimally invasive approach, such as in those with extremely large bulky uteri
Magtibay, MD Mayo Clinic, AZ making traditional laparoscopic hysterectomy difficult.
In recent years there has been a renewed interest in supracervical hysterectomies. This is a case of a 39 year old gravida 3 para 3 woman who presented with a
Reported outcomes have shown that up to 24% of women undergoing large, bulky fibroid uterus causing menorrhagia, dysmenorrhea, and pelvic pain
supracervical hysterectomy require re-operation secondary to neoplasia, cyclical symptoms. Childbearing was complete. She had failed medical management in
bleeding, pelvic pain, dyspareunia, and vaginal discharge. We present a patient the past and desired definitive management with hysterectomy. Uterine depth
with a history of chronic pelvic pain and multiple abdominal surgeries. She sounded to 13 cm and on pelvic MRI the uterus measured 15 x 7 x 12 cm. The
underwent supracervical hysterectomy several years prior secondary to uterine largest fibroid was posterior, measured 9cm, and filled the pelvis. The patient
leiomyomata. We demonstrate the robotic approach to deep pelvic dissection with was offered a robotic assisted total laparoscopic hysterectomy of this very large
isolation of the ureters and removal of the cervical stump. The robotic system bulky uterus in order to avoid laparotomy.
facilitates careful dissection of the cervix and identification of the ureters which is
essential in order to avoid injury to the surrounding pelvic structures. This video presentation illustrates the careful and precise dissection made
possible using the assistance of the daVinci robot. The magnified three-
V008: A PECULIAR VASCULAR INJURY IN ROBOTIC HYSTERECTOMY dimensional vision and the precision and dexterity of the robotic instruments
Rhoda Raji, MD, Karim ElSahwi, MD, Masoud Azodi, MD Yale-New Haven facilitated manipulation of the uterus and dissection of the retroperitoneal
Hospital space allowing for efficient and safe removal of this bulky uterus in a minimally
invasive manner. Approach to the side-wall to side-wall uterus is discussed and
Objectives: To present a case of external iliac vein injury during extraction of the
techniques for manipulating and removing such a large structure are illustrated.
uterus and to demonstrate its management
Methods: A video presentation V012: ROBOTIC APPENDECTOMY DURING GYNECOLOGIC SURGERY:
3 DIFFERENT TECHNIQUES Taryn N Gallo, MD, Dan-Arin Silasi, MD,
Results: This video shows an injury to the right external iliac vein during vaginal
Masoud Azodi, MD Yale New Haven Health / Bridgeport Hospital
extraction of the uterus after completion of a robotic-assisted hysterectomy. A
uterine manipulator had not been used, and upon trying to reach the 16-week Background: Appendectomy is a common procedure during gynecologic surgery.
size fibroid uterus with a single-toothed tenaculum introduced through the There are numerous indications including endometriosis, pelvic pain, abnormal
vagina, the right external iliac vein was inadvertently pierced. The robot was appearance, and malignancy.
used to disengage the tenaculum and repair the vein. The case was not converted Objective: To demonstrate three different techniques for appendectomy during
and the patient suffered no short or long term squeals. robotic gynecologic surgery. Methods: Three robotic cases are presented focusing
Conclusion: The tips of all instruments should be always kept in full view. on technique for appendectomy. Conclusion: Robotic appendectomy can be
Consistent adherence to the rules of laparoscopy prevents untoward consequences. performed using several methods during gynecologic surgery when indicated.

www.mirasurgery.org 29
Video Abstracts
V013: ROBOTIC RADICAL PROSTATECTOMY IN GREECE:5-YEAR Open surgery, endoscopic and laparoscopic techniques are surgical options for
EXPERIENCE Nick Pardalidis, Nick Andriopoulos, Aggelos Karamanis, Niki the management of bladder diverticuli. We report photoselective vaporization of
Giannakou, Eleni Kosmaoglou Athens Medical Centre, Marousi, Greece the prostate (PVP) and robot-assisted bladder diverticulectomy (RABD) in the
same patient for the management of a large symptomatic bladder diverticulum.
Purpose: Radical prostatectomy is the treatment of choice for the management of
organ confined prostate cancer. Minimal invasive treatments as an alternative, Materials & Methods: A 57 year old patient with bladder outlet obstruction and a
have been refined recently by the addition of the da Vinci robotic technology secondary large bladder diverticulum underwent sequential PVP and RABD.
which has the potential to improve surgical outcomes and reduce the steep The size of the diverticulum was 8x7x6 cm. PSA was 1,8 ng/dl, prostate volume
learning curve associated with conventional laparoscopic radical prostatectomy. 30cc, post-void residual 500cc and flow rate was 5 ml/sec. Cystoscopy revealed
We report our 5-year experience with robotic radical prostatectomy using the obstruction due to lateral prostatic lobes and bladder neck stricture. After
da Vinci robotic system. the PVP procedure a 20 Fr open-end urethral catheter was inserted into the
diverticulum via a guide wire, in order to distend it with normal saline infusion.
Materials & Methods: Since 2006, more than 200 robotic radical prostatectomies
The distended diverticulum was easily detected and transected at its neck from
were performed by a single surgical team at Athens Medical Centre (Marousi,
Greece). Preoperative data collection included basic demographics, prostate the bladder using the da Vinci robotic system. The bladder opening was closed
in two separate layers and was checked for watertight closure by instilling saline
specific antigen (PSA), clinical stage and Gleason score. Operative outcomes
through the urethral catheter.
included operative time, estimated blood loss and complications. Postoperative
outcomes included hospital stay, pain, catheter time, pathology, PSA, return of Results: The total operative time was 145 min. No intraoperative complications
continence and potency. were encountered. The patient was discharged the following day and the catheter
was removed on the fifth postoperative day after cystographic examination.
Results: Average operative time was 168,25 minutes with an estimated mean
Flexible cystoscopy revealed no evidence of residual diverticula. The patient had
blood loss of 135ml. 90% of the patients were discharged home on postoperative
uneventful recovery and excellent urination after catheter removal.
day 1. All patients reported minimal postoperative pain and resumed regular
diet on the first postoperative day. Average catheter time was 6,6 days Conclusions: Sequential PVP and RABD appear to be a safe, effective as well as
(range 5-10). Our potency results demonstrate that surgical skills along with minimally invasive alternative procedure for the management of large bladder
athermal technique are the key points for the preservation of the neurovascular diverticulum.
bundle. Early continence was observed in 57,5% of the patients, 7 days after
catheter removal. Continence at 1, 3 and 6 months was 82,5%,88% and 95% V016: ROBOTIC ASSISTED ANTERIOR EXENTERATION FOR
respectively. The overall positive margin rate was 15,5%. 95% of the patients URETHRAL CANCER Rhoda Raji, MD, Karim Elsahwi, MD, Masoud Azodi
had undetectable postoperative PSA levels (less than 0,1ng/ml) at a median Department of Obstetrics, Gynecology and Reproductive Sciences, Yale-New
follow up of 24 months. Haven Hospital, New Haven, CT, 06520
Conclusions: Our experience with robotic radical prostatectomy proves that Objectives: To describe robotic assisted anterior exenteration in a 43 year-old
yhe method is safe and effective, combining the minimal morbidity with good patient with urethral cancer.
oncological and functional outcomes. Methods: A video presentation
V014: ROBOTIC-ASSISTED INSERTION OF AN ARTIFICIAL URINARY Results: A 43 year-old woman presents with irritative and obstructive urinary
SPHINCTER AFTER PELVIC TRAUMA AND URETHRAL DISRUPTION symptoms, a urethral diverticulum is diagnosed. Diverticulectomy reveals
Jonathan J Melquist, MD, Ruth Ann Miles, MD, Zelik Frischer, MD, Rahuldev adenocarcinoma originating in urethral glands. She receives four cycles
Bhalla, MD Stony Brook University Medical Center of cisplatinum and docetaxel with partial response. PET-CTshows a 4 cm
urethral mass invading the base of the bladder. No metastases are reported.
Objective: Implantation of artificial urinary sphincter is an established procedure She undergoes a robotic-assisted anterior exenteration. Urinary diversion
for urinary incontinence. We report on a novel robotic technique for the is performed by urology service through a minilaparotomy. Neovaginal
placement of an artificial urinary sphincter (AUS) in a female patient after major reconstruction performed by plastics service. Post operative course is
pelvic trauma and complete urethral disruption. complicated by bleeding from the neovagina flap managed by embolization.
Patients & Methods: A 53 year-old female presents with urinary incontinence after Conclusion: The meticulous dissection advantages and minimally invasive virtues
a motorcycle crash, which resulted in a pubic symphysis fracture, sacro-iliac offered by the da Vinci Robot allows it to yield itself favorably in complicated
disruption, and urethral disruption. The patient failed multiple other surgical gynecologic oncology procedures. Exenteration is nonetheless major surgery
interventions to treat her Type III SUI. Robotic-assistance was utilized in aiding warranting close observation in the postoperative period.
placement of an AUS in the face of technically challenging anatomy.
Results: Robotic-assistance was successfully employed for the dissection for an V017: ROBOT-ASSISTED LAPAROSCOPIC RADICAL
AUS in this technically challenging patient with previous pelvic trauma and CYSTOPROSTATECTOMY: TOTALLY INTRACORPOREAL STUDER
multiple incontinence surgeries. Total robotic operative time was 2.5 hours. NEOBLADDER Nick Pardalidis, Nick Andriopoulos, Niki Giannakou, Evagelia
Estimated blood loss was minimal at 50 mL. The patient was discharged from Karagianni, Eleni Kosmaoglou Athens Medical Center, Maroussi, Athens,
the hospital Post-Operative Day 4 with minimal narcotic use and the catheter Greece
was removed on Day 7. The sphincter was activated after 6 weeks. The patient Objectives: To describe da Vinci laparoscopic radical cystoprostatectomy and
is currently continent with use of the AUS and went from using 3-4 pads/day to intracorporeal ileal Studer neobladder formation.
0-1 pads/day.
Materials: We performed robot-assisted laparoscopic radical
Conclusion: To our knowledge this is the first report of robotic-assistance in cystoprostatectomies and intracorporeal construction of orthotopic Studer
placement of an AUS in a female patient. The robotic assistance allowed us to neobladder in 5 patients.
meticulously dissect the periurethral tissue off the vaginal wall with minimal
morbidity. This was technically feasible and necessary in this otherwise Summary of results: The mean operative time was 7.5 hours. The mean blood loss
inoperable patient. was 140ml. There were no intraoperative or postoperative complications and
the patients’ hospital stay was 5 days. Good oncological and functional results
V015: SEQUENTIAL PHOTOSELECTIVE VAPORIZATION OF THE were encountered at early follow up.
PROSTATE AND ROBOT-ASSISTED LAPAROSCOPIC BLADDER Conclusion: Our initial experience with robotic-assisted laparoscopic radical
DIVERTICULECTOMY Nick Pardalidis, Nick Andriopoulos, Aggelos cystoprostatectomy appears to be favorable with acceptable operative, pathologic
Karamanis, Eleni Kosmaoglou Athens Medical Centre and short-term clinical outcomes.
Purpose: Bladder diverticula are herniations of the bladder mucosa through
the bladder musculature. Acquired bladder diverticula are the result of outlet
obstruction caused mostly by benign prostatic enlargement or bladder neck stricture.

30 6 TH ANNUAL MIRA CONGRESS May 11-13, 2011


V018: ROBOTIC THYMECTOMY IN A CHILD WITH MYESTHENIA V020: ROBOTIC-ASSISTED THORACOSCOPIC REPAIR OF A
GRAVIS Jacob Stephenson, MD, John J Meehan, MD FACS, Daniel Ledbetter, DIAPHRAGMATIC HERNIA WITH LIVER HERNIATION AND
MD Seattle Children’s Hospital ENDOMETRIOSIS CAUSING RECURRENT CATAMENIAL
PNEUMOTHORAX Gary S Schwartz, MD, Koji Park, MD, Syed Razi, MD,
A child with global weakness was diagnosed with myesthenia gravis. Medical
Scott J Belsley, MD, Faiz Y Bhora, MD, Cliff P Connery, MD St. Luke’s-
therapy was fairly ineffective and the patient underwent a robotic thymectomy
Roosevelt Hospital Center
through the left chest. We present this procedure in a video presentation and
demonstrate the utility of the new 8.5 mm 3-D HD scope used for this procedure. Introduction: We describe a case of recurrent catamenial pneumothorax
associated with a diaphragmatic hernia with liver herniation and endometriosis.
V019: ROBOTIC MICROSURGICAL NERVE GRAFTING FOR Primary repair with a human acellular dermis overlay was accomplished via
SYMPATHECTOMY REVERSAL: TECHNIQUE AND FEASIBILITY FOR robotic-assisted thoracoscopy.
FIRST HUMAN CASE M. Jawad Latif, MD, Koji Park, MD, Syed S Razi, MD,
Methods: One of multiple small diaphragmatic nodules was excised with
Faiz Bhora, MD, George Todd, MD, Noel Perin, MD, Cliff Connery, MD, Scott
electrocautery. The diaphragm was mobilized circumferentially from the liver,
J Belsley, MD St. Luke’s Roosevelt Hospital Center, Columbia University
which was herniating through the diaphragmatic defect. Primary repair of the
Objective: Compensatory sweating (CS) is a well established side effect in hernia was accomplished with interrupted 0-Ethibond sutures. Several attenuated
patients undergoing thoracoscopic sympathectomy for Primary Hyperhydrosis. areas of the diaphgragm were noted. The decision was made to overlay with
There are no effective medical treatment options for debilitating CS. Our diaphragm in order to induce fibrosis and seal any potential fenestrations. A
objective was to restore anatomic and possible physiological function using piece of human acellular dermis was sutured circumferentially with interrupted
microsurgical techniques with autologous nerve grafts. This study follows our 0-Ethibond sutures. A completion pleurectomy was then performed.
success on a porcine model developed in our laboratory where sympathetic
Results: There were no intraoperative or postoperative complications. The total
chain reconstruction was achieved in a minimally invasive fashion with standard
operative time was 4:28. The patient’s chest tubes were removed and she was
neurosurgical principals and microsurgery using the da Vinci robot. We describe
discharged home on the third postoperative day. Histological evaluation of the
this novel application of the da Vinci robot in a human patient suffering from a
diaphragmatic nodule revealed mesothelial proliferation with no evidence of
decline in quality of life and severe CS after thoracoscopic sympathectomy.
endometriosis.
Methods & Procedures: A first generation da Vinci system was used for this
Conclusions: Primary repair of a diaphragmatic hernia with a human acellular
operation. Reversal was performed on both sides with the patient in lateral
dermis overlay via robotic assisted thoracoscopy is safe and feasible.
decubitus position requiring undocking the robot and flipping the patient mid-
Suturing was facilitated by the superior ergonomics of the robotic approach.
procedure. Single lung ventilation was achieved via double lumen tube. Standard
Circumferentially securing the overlay patch would have been exceedingly
triangulated port placement for three robotic arms was performed under direct
difficult through standard thoracoscopy, given the difficult working angles and
visualization. An additional fourth working port was placed between the camera
limited range of motion within the rigid confines of the chest wall. The robotic
and right robotic arm port. Previous areas of sympathetic interruption were
approach can help overcome the formidable ergonomic challenges associated
identified. By using da Vinci’s magnified view, the sympathetic chain and intact
with performing complex thoracoscopic tasks.
ganglia were carefully dissected between these segments. Two size appropriate
intercostal nerve grafts were harvested from third and fourth intercostal rib V021: NOT A MATTER OF SIZE Vasiliki Chatzirafail, MD, Michael Litos, MD
spaces respectively and used as direct grafts and in one case as an interposition PhD MRCOG, Antigoni IssarI, MD Euroclinic, Athens, Greece
graft to restore continuity of sympathetic chain. Tension free nerve anastomoses
were performed between identifiable isolated gnglia via 8-0 Prolene interrupted It is often thought that large size is the only limiting factor for endoscopic
sutures which were further supported by pleural buttress as necessary. myomectomy, and that small fibroids can be easily excised laparoscopically or
robotically. We present a video indicating that small size can be a draw back and
Preliminary Results: The operation was successfully accomplished robotically that location can be equally important, if not more so.
without any need of conversion to open surgery in about 9 hours. Right sided
operation took approximately six hours while the contralateral side was A 44 years old, para 2, woman presented with persistent pelvic pain and
considerably faster. The patient tolerated intermittent thoracic insufflation and dyspareunia. Ultrasonographic examination revealed a 6cm fibroid located
single lung ventilation. The patient was hyperthermic with manipulation of to the left of the cervix. Hysterectomy was discussed and declined, so it was
the ganglia but remained hemodynamically stable with minimal blood loss and decided to have a robotic myomectomy. At the operation the fibroid was not
an uncomplicated post operative course. Patient was discharged home on post visible even after opening the broad ligament and dissecting the ureter and the
operative day 1. On short term follow up, patient did not have any evidence of uterine vessels and exposing the lateral part of the uterus. Not being possible
Horner’s syndrome. Long term results of functional outcome are pending. to indetifiy the fibroid, stripping the left side of the uterus and cervix was
innevitable and the operation was converted to robotic total hysterectomy. The
Conclusions/Expectations: This novel application of da Vinci robot for thoracic operation was completed uneventfully and the fibroid was found attached to the
sympathetic chain reconstruction is technically feasible in human subjects. The lower end of the cervix.
3-D magnification and manual dexterity of robot allows for nerve microsurgery
in a minimally invasive fashion as compared to standard thoracotomy. Although Robotic assistance provides good access, stereoscopic view and precise
functional outcome for autonomic reconstruction is unknown, it is expected to maneuvers that facilitate excision of fibroids in difficult positions or of big size,
yield comparable results to an open operation. Further investigation is ongoing. as suggested by our experience that we present elsewhere. In this particular case
it was not possible to perform a myomectomy and this was not a matter of size.

V022: ROBOTIC SURGERY FOR ENDOMETRIOSIS UTILIZING THE 5MM


DAVINCI SYSTEM Taryn n Gallo, MD, Masoud Azodi, MD Yale New Haven
Health / Bridgeport Hospital
Objective: To present our experience utilizing the 5mm pediatric instruments
with robotic surgery for significant endometriosis.
Method: Case presentation utilizing the 5mm pediatric instruments for a 23 year
old patient with bilateral endometriomas and significant adhesive disease.
Conclusion: Although there is no bipolar instruments or hot scissors, robotic
surgery for gynecologic indications can be performed utilizing the 5mm system.
The benefits include improved cosmesis with smaller incisions and decreased
risk for incisional hernia.

www.mirasurgery.org 31
Poster List
P001 ROBOTICS ENABLES A MINIMALLY INVASIVE APPROACH TO RIGHT SIDED EPIPHRENIC DIVERTICULUM Barbara Tempesta, CRNP, Marc Margolus,
MD, Eric Strother, CSA, Farid Gharagozloo, MD, Washington Institute Of Thoracic And Cardiovascular Surgery; The George Washington University Medical Center
P002 ROBOTIC APPROACH TO A LEFT SIDED EPIPHRENIC DIVERTICULUM Farid Gharagozloo, Marc Margolis, MD, Eric Strother, CSA, Barbara
Tempesta, CRNP, Washington Institute Of Thoracic And Cardiovascular Surgery; The George Washington University Medical Center
P003 ROBOTIC LAPAROSCOPIC GASTROESOPHAGEAL VALVULOPLASTY FOR THE TREATMENT OF GASTROESOPHAGEAL REFLUX DISEASE
Farid Gharagozloo, MD, Eric q Strother, CSA, Marc Margolis, MD, Barbara Tempesta, CRNP, Washington Institute Of Thoracic And Cardiovascular Surgery; The
George Washington University Medical Center
P004 ROBOT-ASSISTED THORACOSCOPIC RIGHT UPPER LOBECTOMY FOR EARLY STAGE LUNG CANCER - A VIDEO PRESENTATION OF ROBOT
POSITIONING AND OPERATIVE TECHNIQUE Farid Gharagozloo, Marc Margolis, MD, Eric Strother, CSA, Barbara Tempesta, CRNP, Washington Institute
Of Thoracic And Cardiovascular Surgery; The George Washington University Medical Center
P005 DECREASED POST-OPERATIVE PAIN WITH A NOVEL PORT CLOSURE IN THORACIC ROBOTIC SURGERY Eric Strother, CSA, Marc Margolis,
MD, Barbara Tempesta, CRNP, Farid Gharagozloo, MD, Washington Institute Of Thoracic And Cardiovascular Surgery; The George Washington University
Medical Center
P006 ROBOTIC SEGMENTECTOMY OF EARLY STAGE LUNG CANCER Farid Gharagozloo, Marc Margolis, MD, Eric Strother, CSA, Barbara Tempesta,
CRNP, Washington Institute Of Thoracic And Cardiovascular Surgery; The George Washington University Medical Center
P007 ROBOTIC SURAL NERVE GRAFT FOR REVERSAL OF THORACIC SYMPATHECTOMY Farid Gharagozloo, Marc Margolis, MD, Eric Strother, CSA,
Barbara Tempesta, CRNP, Washington Institute Of Thoracic And Cardiovascular Surgery; The George Washington University Medical Center
P008 ROBOTIC ASSISTED THORACOSCOPIC RESECTION OF BRONCHOGENIC CYSTS Farid Gharagozloo, MD, Barbara Tempesta, CRNP, Eric Strother,
CSA, Marc Margolis, MD, Washington Institute Of Thoracic And Cardiovascular Surgery; The George Washington University Medical Center
P009 ROBOTIC RELIEF TO THE MEDIAN ARCUATE SYNDROME Farid Gharagozloo, MD, Marc Margolis, MD, Eric Strother, CSA, Barbara Tempesta,
CRNP, Washington Institute Of Thoracic And Cardiovascular Surgery; The George Washington University Medical Center
P010 SUBPLEURAL CATHETER PLACEMENT FOR POST-OPERATIVE PAIN - TECHNIQUE AND INTERMEDIATE TERM RESULTS Barbara Tempesta,
CRNP, Marc Margolis, MD, Eric Strother, CSA, Farid Gharagozloo, MD, Washington Institute Of Thoracic And Cardiovascular Surgery; The George Washington
University Medical Center
P011 PROLONGED OPERATIVE TIME IN ROBOTIC TOTALLY ENDOSCOPIC TOTALLY ENDOSCOPIC COR ONARY BYPASS SURGERY – IS IT AN
ISSUE? Dominik Wiedemann, Nikolaos Bonaros, Thomas Schachner, Felix Weidinger, Eric Lehr, Mark Vesely, Guy Friedrich, Johannes Bonatti, 1 University
Clinic of Cardiac Surgery, Innsbruck Medical University, Austria 2 Division of Cardiac Surgery, Department of Surgery, University of Maryland, USA 3 Division of
Cardiology, University of Maryland, USA 4 Department of Cardiology, Innsbruck M
P012 EARLY AND MIDTERM RESULTS OF TOTALLY ENDOSCOPIC CORONARY ARTERY BYPASS GRAFTING ON BEATING HEART Changqing Gao,
MD, PLA General Hospital
P013 ROBOTIC TOTALLY ENDOSCOPIC CORONARY ARTERY BYPASS GRAFTING FOR SPONTANEOUS CORONARY ARTERY DISSECTION Brody
Wehman, MD, Eric Lehr, MD PhD, Ratnakar Mukherjee, MD, Alina Grigore, MD, Bartley Griffith, MD, Johannes Bonatti, MD, University of Maryland Medical Center
P014 ROBOTIC APPROACH TO GIANT HIATAL HERNIAS WITH PRIMARY REPAIR OF THE DIAPHRAGMATIC HERNIA Sigrid Bairdain, MD, Marc
Margolis, MD, Barbara Tempesta, CRNP, Eric Strother, CSA, Farid Gharagozloo, MD, Washington Institute of Thoracic and Cardiovascular Surgery; The George
Washington University Medical Center
P015 SHORT-TERM ANGIOGRAPHIC RESULTS OF ROBOTICALLY ASSISTED CORONARY ANASTOMOSIS USING CONVENTIONAL AND CT-
ANGIOGRAPHY Nikolaos Bonaros, MD, Felix Weidinger, MD, Benedikt Hofauer, MD, Gudrun Feuchtner, MD, Fabian Plank, Guy Friedrich, MD, Eric Lehr,
MD, Johannes Bonatti, MD, Thomas Schachner, Md, Department iof Cardiac Surgery, Innsbruck Medical University
P016 CAUSES AND CONSEQUENCES OF POSTOPERATIVE ATRIAL FIBRILLATION IN TOTALLY ENDOSCOPIC CORONARY BYPASS SURGERY Felix
Weidinger, MD, Thomas Schachner, MD, Nikolaos Bonaros, MD, Benedikt Hofauer, Eric J Lehr, MD, Mark Vesely, MD, David Zimrin, MD, Johannes O Bonatti,
MD, Innsbruck Medical University, Department of Cardiac Surgery; University of Maryland Medical Center, Division of Cardiac Surgery
P017 A COMPARATIVE STUDY ON ROBOTIC VERSUS OPEN RIGHT HEMICOLECTOMY FOR CANCER F. Luca, MD, M. Valvo, MD, S. Cenciarelli, MD,
T. Leal Ghezzi, MD, M. Zuccaro, MD, S. Pozzi, MD, R. Biffi, MD, Division of Abdomino-Pelvic Surgery, European Institute of Oncology; Milan, Italy
P018 THE LEARNING CURVE IN RECTAL RESECTION: IS IT FASTER IN ROBOTICS THAN IN LAPAROSCOPY? Olivia Sgarbura, MD PhD, Serban Vasile,
MD, Mihai Eftimie, MD, Irinel Popescu, MD PhD FACS, Fundeni Institute of Digestive Diseases and Liver Transplantation, Bucharest, Romania; University of
Medicine and Pharmacy, Bucharest, Romania
P019 ROBOTIC SURGICAL REMOVAL FOR RECURRENT PELVIC TUMOR AFTER COLON CANCER RESECTION Sorin Paun, PhD, Roxana Ganescu,
MD, I Negoi, MD, Mihaela Burtea, MD, M Beuran, PhD, Emergency Hospital – Bucharest, Romania
P020 ROBOTIC VERSUS LAPAROSCOPIC COLON AND RECTAL SURGERY: EARLY COMPARISONS. Grace Montenegro, MD, Rami Makhoul, MD,
Vincent Obias, MD, George Washington University
P021 LESSONS LEARNT FROM INTRODUCTION OF ROBOTIC COLORECTAL SURGERY IN A SPANISH UNIVERSITY HOSPITAL Elena Ortiz-Oshiro,
MD PhD, Angel Ramos Carrasco, MD PhD, Cristina Pardo Martinez, MD PhD, Iris Sanchez Egido, PhD, Jaime González Taranco, PhD, Jesus Alvarez Fernández-
Represa, MD PhD, Hospital Clinico San Carlos - Universidad Complutense de Madrid
P022 ROBOTIC COLECTOMIES: A SERIES OF 122 CASES Francesca Bazzocchi, MD, Domenico Garcea, MD, Andrea Avanzolini, MD, Barbara Perenze, MD,
Morgagni-Pierantoni Hospital - Forlì -Italy
P023 RE-LEARNING CURVE IN ROBOTIC COLORECTAL SURGERY WITH A NEW DA VINCI SI HD G Spinoglio, MD, R Quarati, MD, F Priora, MD, LM
Lenti, PHD, F Ravazzoni, PHD, V Maglione, MD, Division of Oncologic General Surgery, ASO “SS Antonio e Biagio e Cesare Arrigo”, Alessandria , Italy
P024 COMPARISON OF ROBOTICALLY PERFORMED AND TRADITIONAL LAPAROSCOPIC COLORECTAL SURGERY. HC Pappis, MD PhD FACS, N
Pararas, MD PhD, D Kotsakou, MD, ’Hygeia’ Hospital, Athens, Greece
P025 ROBOT IN TREATING WELL-SELECTED LEFT-SIDED PANCREATIC CANCER- ROBOTIC ANTERIOR RAMPS Chang Moo Kang, Yonsei University
College of Medicine
32 6 TH ANNUAL MIRA CONGRESS May 11-13, 2011
P026 TRANSHIATAL VERSUS THORACOSCOPIC ROBOTIC ESOPHAGEAL DISSECTION Carlos Loureiro González, Ismael Díez del Val, title, Inmaculada
Cruz González, Saioa Leturio Fernández, Sandra Ruiz Carballo, José Esteban Bilbao Axpe, José Ramón Cotano Urrutikoetxea, Jaime Jesús Méndez Martín,
Gastroesophageal Surgery Unit, Hospital Basurto, Bilbao
P027 AN INTERNATIONAL SURVEY TO EXAMINE ATTITUDES TOWARDS ROBOTIC SURGERY Sheraz R Markar, MRCS MA MBBChir, Ivana Kolic,
MBBS, Alan P Karthikesalingam, MRCS MA MBBChir, Oliver J Wagner, MD, Monika E Hagen, MD, University College London Hospital
P028 ROBOTIC HELLER MYOTOMY: LEARNING CURVE, ADVANTAGES, AND LIMITATIONS Eric C Nelson, MD, Mohamed R Ali, MD, William Smith,
BS, Tamas J Vidovszky, MD, University of California, Davis Medical Center, Sacramento, CA
P029 INITIAL EXPERIENCES OF ROBOT-ASSISTED POSTERIOR RETROPERITONEOSCOPIC ADRENALECTOMY (PRA); SINGLE PORT ACCESS
Sang-Wook Kang, MD, Haeng Rang Ryu, MD, Jong Ju Jeong, MD, Woong Youn Chung, MD, Department of Surgery, Yonsei University College of Medicine
P030 ADVANTAGES OF ROBOTIC GASTRECTOMY IN EXTRAPERIGASTRIC LYMPHADENECTOMY COMPARED TO LAPAROSCOPIC
GASTRECTOMY Kazutaka Obama, MD PhD, Woo Jin Hyung, MD PhD, Yanghee Woo, MD, Kyung Ho Pak, MD, Hyoung-Il Kim, MD PhD, Sung Hoon Noh,
MD PhD, Department of Surgery, Yonsei University College of Medicine
P031 ROBOTIC REDO FOR FAILED LAPAROSCOPIC NISSEN FUNDOPLICATION Ismael Díez del Val, Carlos Loureiro González, Sandra Ruiz Carballo,
Saioa Leturio Fernández, Inmaculada Cruz González, José Esteban Bilbao Axpe, Jaime Jesús Méndez Martín, Ángel Gómez Palacios, Gastroesophageal Surgery
Unit, Hospital de Basurto, Bilbao, Spain
P032 TOTALLY ROBOTIC SUBTOTAL GASTRECTOMY FOR CANCER Carlos Loureiro González, Ismael Díez del Val, Inmaculada Cruz González, Saioa
Leturio Fernández, Sandra Ruiz Carballo, José Esteban Bilbao Axpe, Jaime Jesús Méndez Martín, Gastroesophageal Surgery Unit, Hospital de Basurto, Bilbao
P033 FROM LAPAROSCOPIC TO ROBOTIC GASTROESOPHAGEAL SURGERY Ismael Díez del Val, Carlos Loureiro González, Sandra Ruiz Carballo, Saioa
Leturio Fernández, Inmaculada Cruz González, José Esteban Bilbao Axpe, Jaime Jesús Méndez Martín, Ángel Gómez Palacios, Gastroesophageal Surgery Unit,
Hospital de Basurto, Bilbao
P034 ROBOT-ASSISTED TRANSHIATAL ESOPHAGECTOMY Carlos Loureiro González, Ismael Díez del Val, José Esteban Bilbao Axpe, José Ramón Cotano
Urrutikoetxea, Jaime Jesús Méndez Martín, Gastroesophageal Surgery unit, Hospital de Basurto, Bilbao
P035 ROBOT-ASSISTED THYROIDECTOMY BY TRANSAXILLARY APPROACH Nicolae Constantea, Profesor PhD MD, Dan Axente, MD, 5th Surgical
Clinic, Cluj-Napoca County Hospital, Romania
P036 FEASIBILITY AND SAFETY OF ROBOT ASSISTED-ENDOSCOPIC THYROIDECTOMY-SYSTEMATIC REVIEW Eugenia Yiannakopoulou, MD
Msc PhD, Nikolaos Nikiteas, MD PhD, Christos Tsigris, MD PhD, Faculty of Health and Caring Professions Technological Educational Institute of Athens, 2nd
Department of Propedeutic Surgery School of Medinice NKUA, 1st Department of Surgery School of Medicine NKUA
P037 FEASIBILITY AND SAFETY OF ROBOT ASSISTED-ADRENALECTOMY -SYSTEMATIC REVIEW Eugenia Yiannakopoulou, MD Msc PhD, Nikolaos
Nikiteas, MD PhD, Christos Tsigris, MD PhD, Faculty of Health and Caring Professions Technological Educational Institute of Athens, 2nd Department of
Propedeutic Surgery School of Medinice NKUA, 1st Department of Surgery School of Medicine NKUA
P038 A PROSPECTIVE COMPARISON OF THE VOICE QUALITY AFTER ROBOTIC VERSUS CONVENTIONAL OPEN THYROIDECTOMY FOR THE
PAPILLARY THYROID CANCER 2Jong Ho Yoon, 3Chi Young Lim, 1Kyu Hyung Kim, 1Jae Hyun Park, 1Sohee Lee, 1Haeng Rang Ryu, 1Sang-Wook Kang, 1Jong
Ju Jeong, 1Kee-Hyun Nam, 1Woong Youn Chung, 1Cheong Soo Park, 1Yonsei University College of Medicine,2Asan Medical Center, University of Ulsan College
of Medicine, 3National Health Insurance Corporation Ilsan Hospital
P039 INTRAOPERATIVE NEUROMONITORING OF THE EXTERNAL BRANCH OF THE SUPERIOR LARYNGEAL NERVE DURING ROBOTIC
THYROID SURGERY Su-jin Kim, Kyu Eun Lee, Mi Ra Kwon, Kwan Yoon, Hyuk Jae Choi, Jun Young Choi, Yeo-Kyu Youn, Haeundae Paik Hospital, Seoul
National University Hospital, Korea
P040 ROBOTIC SURGERY FOR MORBID OBESITY: ROUX-EN-Y GASTRIC BYPASS, GASTRIC BANDING, SLEEVE GASTRECTOMY Christina
Delimpalta, Archontis Zampogiannis, NATIONAL AND CAPODISTREAN UNIVERSITY OF ATHENS, MEDICAL SCHOOL and 1st SURGICAL CLINIC,
LAIKON HOSPITAL, ATHENS, GREECE
P041 ENDOSCOPIC AND ROBOTIC THYROID SURGERY WITH LATERAL NECK DISSECTION FOR PAPILLARY THYROID CARCINOMA USING A
BILATERAL AXILLO-BREAST APPROACH June Young Choi, MD, Kyu Eun Lee, MD PhD, Yeo-Kyu Youn, MD PhD, Seoul National University Hospital
P042 ROBOTIC APPROACH FOR ABDOMINAL HERNIAS – A ROMANIAN EXPERIENCE Sorin Paun, PhD, Roxana Ganescu, MD, M Beuran, PhD, C
Turculet, PhD, F Iordache, PhD, I Negoi, MD, D Surdeanu, MD, Emergency Hospital – Bucharest, Romania
P043 ROBOTIC APPROACH FOR HYDATID HEPATIC CYSTS Sorin Paun, PhD, Roxana Ganescu, MD, I Negoi, MD, Mihaela Burtea, MD, B Gaspar, PhD, M
Beuran, PhD, Emergency Hospital – Bucharest, Romania
P044 ROBOTIC ADRENALECTOMY FOR BENIGN AND MALIGNANT PATHOLOGIES Archontis Zampogiannis, Christina Delimpalta, NATIONAL AND
CAPODISTREAN UNIVERSITY OF ATHENS, MEDICAL SCHOOL and 1st SURGICAL CLINIC, LAIKON HOSPITAL, ATHENS, GREECE
P045 GIST DUODENAL RESECTION AND RECONSTRUCTION IS A FEASIBLE ROBOTIC PROCEDURE T . P Singh, MD, Eyad Wohaibi, MD, James
Massullo, MD, Department of Surgery Albany Medical Center
P046 COMPARISON OF SUTURING TASKS USING THE DA VINCI SINGLE-SITE INSTRUMENTS SYSTEM AND LAPAROSCOPIC SINGLE SITE
INSTUMENTS Tamas J Vidovszky, MD, Bernadette Guiroy, MD, Dan Eisenberg, MD, James Lau, MD, Homero Rivas, MD, University of California, Davis
Medical Center, Sacramento, CA; Salinas Memorial Hospital, Salinas, CA; Stanford School of Medicine, Palo Alto, CA
P047 COMPARISON OF PERIOPERATIVE OUTCOMES BETWEEN HAND-ASSISTED LAPAROSCOPIC WHIPPLE’S OPERATION AND ROBOT-
ASSISTED LAPAROSCOPIC WHIPPLE’S OPERATION Eric C.H. Lai, MBChB MRCSEd FRACS, Chung Ngai Tang, MBBS FRCS, George P.C. Yang, MBBS
MRCSEd FRACS, Oliver C.Y. Chan, MBChB MRCSEd FRCS, Michael K.W. Li, MBBS FRCS, Department of Surgery, Pamela Youde Nethersole Eastern Hospital,
Chai Wan, Hong Kong SAR, China
P048 REVISION OF NISSEN FUNDOPLICATION TO ROUX-EN-Y GASTRIC BYPASS WITH THE ROBOTIC SYSTEM DA VINCI. HC Pappis, MD PhD
FACS, N Pararas, MD PhD, D Kotsakou, MD, ’Hygeia’ Hospital, Athens, Greece
P049 ROBOTIC VERSUS LAPAROSCOPIC ROUX-EN-Y GASTRIC BYPASS: META-ANALYSIS Sheraz R Markar, MRCSEng MAcantab, Alan P Karthikesalingam,
MRCSEng MACantab, Sri Thurumathy, MBBS, James Kinross, MRCSEng PhD, Paul Ziprin, FRCS PhD, Academic Surgical Unit, St Mary’s Hospital, Imperial College, UK

www.mirasurgery.org 33
Poster List
P050 ROBOT-ASSISTED CHOLECYSTECTOMY AS A BRIDGE TO ADVANCED ROBOTIC PROCEDURES HC Pappis, MD PhD FACS, N Pararas, MD PhD,
D Kotsakou, ’Hygeia’ Hospital, Athens, Greece
P051 DYSFUNCTION OF THE DA VINCI SURGICAL SYSTEM DURING 260 VARIOUS ROBOTIC PROCEDURES. Francois Pugin, MD, Bucher Pascal, MD,
Buchs Nicolas, MD, Hagen Monika, MD, Morel Philippe, MD, University Hospitals Geneva, Switerland
P052 ROBOTIC-ASSISTED LAPAROSCOPIC TREATMENT OF LIVER CYSTS Daniel Langer, Miroslav Ryska, Jiri Pudil, Eva Laszikova, Surgery Department,
2nd Faculty of Medicine, Charles University and Central Military Hospital Prague, Czech Republic
P053 TRANSVAGINAL NATURAL ORIFICE TRANSLUMINAL ENDOSCOPIC SURGERY (NOTES)- AN OVERVIEW Christina Delimpalta, Archontis
Zampogiannis, National and Capodistrean University of Athens Medical School and 1st Surgical Clinic, Laikon Hospital, Athens, Greece
P054 NOVEL SLIP AND TACTILE SENSOR SYSTEM ON A MIOGRIPPER Luis Gerardo Sanchez Stone, MSc, Abel Ronquillo, MSc, UPAEP, Ergosolar, LAAR
P055 IN SILICO EXPERIMENTAL MODEL OF AN ASSEMBLING RECONFIGURABLE MODULAR MICRO-ROBOT FOR NOTES SURGERY Apollon
Zygomalas, MD MSc, Konstantinos Giokas, MSc, Dimitrios Koutsouris, Prof, University of Patras, School of medicine, Postgraduate Course in Medical Informatics
P056 SOFIE, A ROBOTIC SYSTEM FOR MINIMALLY INVASIVE SURGERY Linda Van den Bedem, dr ir, Ron Hendrix, ir, Gerrit Naus, dr ir, Ruud Van
der Aalst, ir, Nick Rosielle, dr ir, Henk Nijmeijer, prof dr, Jos Maessen, prof dr, Ivo Broeders, prof dr, Maarten Steinbuch, prof dr ir, Eindhoven University of
Technology, the Netherlands, Academic Hospital Maastricht, the Netherlands, Meander Medical Center Amersfoort, the Netherlands
P057 ROBOTICALLY ASSISTED UKA IS MORE ACCURATE THAN MANUALLY INSTRUMENTED UKA Thomas M Coon, MD, Matthew D Driscoll, MD,
Sharon Horowitz, BS, Michael A Conditt, PhD, St Helena’s Hospital, Scott and White Memorial Hospital, MAKO Surgical Corp
P058 SLEEVE GASTRECTOMY FOR MORBID OBESITY WITH THE USE OF THE DA VINCI SURGICAL SYSTEM. A. ALEXANDROU, IOANNIS
PAPANIKOLAOU, D. DIAMANTIS, N. DIMITRIOU, N. MPASIOS, J. GRINIATSOS, A. GIANNOPOULOS, THEODOROS DIAMANTIS, 1st Department of
Surgery of the University of Athens, Laiko Athens General Hospital, 17 Agiou Thoma St, 11527, Athens, Greece.
P059 CAN TOTALLY ROBOTIC LAPAROSCOPIC GASTRIC BYPASS FOR MORBID OBESITY PRECISELY DUPLICATE ANY TRADITIONAL
LAPAROSCOPIC TECHNIQUE? A. ALEXANDROU, IOANNIS PAPANIKOLAOU, D. DIAMANTIS, N. DIMITRIOU, N. MPASIOS, J. GRINIATSOS, A.
GIANNOPOULOS, THEODOROS DIAMANTIS, From the 1st Department of Surgery of the University of Athens, Laiko Athens General Hospital, 17 Agiou
Thoma St, 11527, Athens, Greece.
P060 REMOTE TELE SURGERY : HELP OF LOSSY VIDEO COMPRESSION FOR THE FUTUR Manuela PEREZ, MD, Nedia NOURI, Jean-Marie
MOUREAUX, Denis ABRAHAM, Michel DUFAUT, Jaques HUBERT, PhD, Centre de Recherche en Automatique de Nancy, Nancy-Université, CNRS 2, avenue
de la forêt de Haye, 54516 Vandœuvre-lès-Nancy, France 2 Centre de Recherche en Automatique de Nancy, Nancy-Université, CNRS Faculté des Sciences, BP
70239, 54506 Vandœuvre-lè
P061 RESULTS OF A PROFICIENCY-BASED CURRICULUM WITH THE VIRTUAL REALITY ROBOTIC SURGERY SIMULATOR: DV-TRAINER.
PERRENOT Cyril, PEREZ Manuela, MD, TRAN Nguyen, MD, HUBERT Jacques, MD, CHU de Nancy
P062 ACCURACY OF ROBOTICALLY ASSISTED ACETABULAR CUP IMPLANTATION Douglas E Padgett, MD, Lawrence D Dorr, MD, Miranda L
Jamieson, MS, Michael A Conditt, PhD, Hospital for Special Surgery, Good Samaritan Hospital, MAKO Surgical Corp
P063 ACCURACY OF UKA COMPONENT PLACEMENT WITH DYNAMICALLY REFERENCED TACTILE ROBOTICS Nicholas D Dunbar, MS, Martin W
Roche, MD, Brian H Park, BS, Sharon Horowitz, BS, Michael A Conditt, PhD, Scott A Banks, PhD, Holy Cross Hospital, University of Florida, MAKO Surgical Corp
P064 HAPTIC ROBOTICS FOR MINIMALLY INVASIVE, MODULAR KNEE ARTHROPLASTY Scott A Banks, PhD, Rony Abovitz, MS, Arthur Quaid, PhD,
Jason K Otto, PhD, Michael A Conditt, PhD, University of Florida, MAKO Surgical Corp
P065 THE LEARNING CURVE OF ROBOTIC-ASSISTED UKA Riyaz Jinnah, MD, Sharon Horowitz, BS, Tamas Erdos, BS, Michael A Conditt, PhD, Wake
Forest University, MAKO Surgical Corp
P066 ROBOTIC SLEEVE GASTRECTOMY. AN INTERMEDIATE APPROACH TO UNDERGO TOTALLY ROBOTIC GASTRIC BY-PASS. RAMON
VILALLONGA, PhD, JOSE MANUEL FORT, PhD, MIRIAM ZAMORA, MONTSERRAT CHINCHILLA, NURIA ROS, OSCAR GONZALEZ, PhD, MANEL
ARMENGOL CARRASCO, PhD, Universitary Hospital Vall d’Hebron. Barcelona.
P067 DEVELOPMENT OF AN AUTOMATED REAL-TIME MR GUIDED ROBOTIC SYSTEM FOR HIGH PRECISION DIAGNOSTIC AND THERAPEUTIC
INTERVENTIONS IN BREAST. Mehran Anvari, MB BS PhD FRCSC FACS, Julian Dobranowski, MD FRCPC, Kevin J Randall, PhD, Peter Lovrics, MD FRCSC,
N Konyer, BSc, T Fielding, MSc, K Morency, MSc, Centre for Surgical Invention and Innovation; MacDonald, Dettwiler and Associates
P068 3D VISUALIZATION AND TRAJECTORY PLANNING SYSTEM FOR REAL TIME INTERVENTION Mehran Anvari, MB BS PhD FRCSC FACS, Bart
Verzijlenberg, MSc, Julian Dobranowski, MD FRCPC, Kevin Randall, PhD, Centre for Surgical Invention and Innovation; MacDonald, Dettwiler and Associates
P069 MINIMIZING HEPATIC TRAUMA WITH A NOVEL LIVER RETRACTION METHOD DURING ROBOTIC AND LAPAROSCOPIC GASTRIC
CANCER SURGERY, A SIMPLE LIVER-SUSPENSION WITH GAUZE-SUTURE TECHNIQUE Yanghee Woo, MD, Kazutaka Obama, MD PhD, Tae-Il Son,
MD, Hyung Il Kim, MD, Woo Jin Hyung, MD PhD, Department of Surgery and Robot and Minimally Invasive Surgery Center at Yonsei University College of
Medicine
P070 DEEP FLEXION KINEMATICS WITH ROBOTIC MODULAR KNEE ARTHROPLASTY Toshifumi Watanabe, MD, Scott A Banks, PhD, Stefan Kreuzer,
MD, Kevin J Leffers, MD, Takeshi Muneta, MD PhD, Michael A Conditt, PhD, Jennifer A Jones, BS, University of Florida, Gainesville, Florida; Memorial Bone
and Joint Research Foundation, Houston, Texas; Tokyo Medical and Dental University, Tokyo, Japan; MAKO Surgical Corporation, Fort Lauderdale, Florida
P071 ROBOTIC SINGLE-SITE CHOLECYSTECTOMY: THE “SINGLE” PORT TO THE FUTURE OF SURGERY? FIRST EXPERIENCE FROM GREECE.
Konstantinos M Konstantinidis, MD PhD FACS, Savas C Hiridis, MD MSc, Periklis S Chrysocheris, MD, Peter C Hiridis, MD, Michael K Georgiou, MD, Athens
Medical Center
P072 LESSONS FROM AVIATION: CHECKLISTING IN FRONT OF THE ROBOTIC SURGICAL ’COCKPIT’. SURGICAL TECHNIQUE CHECKLISTS FOR
INTRAOPERATIVE USE WITH THE DAVINCI SYSTEM. Savas C Hiridis, MD MSc, Konstantinos M Konstantinidis, MD PhD FACS, Petros C Hiridis, MD,
Fotis Antonakopoulos, MD, Dimitris Mousiolis, MD, Kouloufakou Kalliopi, MD, ATHENS MEDICAL CENTER
P073 ROBOTIC TRAINING : LESSONS TO BE LEARNED FROM THE AERONAUTIC PRACTICE ? J. Hubert, MD, G Herrmann, M Perez, MD, C Perrenot,
C Waked, MD, N Hubert, MD, N Tran, MD, 1) Department of Urology, CHU Nancy-Brabois 54511 VANDŒUVRE les NANCY, FRANCE. 2) School of surgery :
UHP-Nancy1, 54500 VANDŒUVRE les NANCY, FRANCE. 3) Air France company, Paris

34 6 TH ANNUAL MIRA CONGRESS May 11-13, 2011


P074 ROBOTIC-ASSISTED GYNECOLOGIC/ONCOLOGIC SURGERY: EXPERIENCE OF EARLY CASES IN A SAUDI ARABIAN TERTIARY CARE
FACILITY Ismail A Al-Badawi, MD, Murad Z Al-Aker, MD, Ibtihal Bukhari, MD, Sarfraz Ahmad, PhD, Jamal Alsubhi, MD, King Faisal Specialist Hospital &
Research Center, Riyadh 11211, Saudi Arabia
P075 ROBOTIC ASSISTED SURGICAL STAGING FOR OVARIAN CANCER IN A PREGNANT WOMAN Ismail A Al-Badawi, MD, Murad Z Al-Aker, MD,
Wesam Kurdi, MD, Jamal Alsubhi, King Faisal Specialist Hospital & Research Center, Riyadh 11211, Saudi Arabia
P076 SURGICAL OUTCOMES WITH ROBOTICS AND MORBIDLY OBESE WOMEN Pamela J Stone, MD, Mohamed Ismaeil, MD, Alexander Burnett, MD,
University of Arkansas for Medical Sciences
P077 ROBOTIC EXTRAPERITONEAL ENDOSCOPIC AORTIC LYMPHADENECTOMY: AN EXPERIMENTAL PIG MODEL Dominique Lanvin, MD,
Monique Bertrand, MD, CSTAR (Canadian Surgical Technologies & Advanced Robotics) Lawson Health Research Institute, London, Ontario, Canada
P078 POSTOPERATIVE PAIN MEDICATION REQUIREMENTS IN PATIENTS UNDERGOING ROBOTICALLY ASSISTED AND STANDARD LAPAROSCOPIC
PROCEDURES FOR NEWLY DIAGNOSED ENDOMETRIAL CANCER Mario M Leitao, MD, Ginger J Gardner, MD, Gabriel Briscoe, Priyal Dholakiya, Kevin Santos,
Elizabeth Jewell, MD, Nadeem R Abu-Rustum, MD, Yukio Sonoda, MD, Richard R Barakat, MD, Vivek Malhotra, MD, Memorial Sloan-Kettering Cancer Center
P079 VAGINAL CUFF DEHISCENCE AFTER ROBOTICALLY ASSISTED PROCEDURES REQUIRING A COLPOTOMY Mario M Leitao, MD, Ginger J
Gardner, MD, Gabriel Briscoe, Elizabeth Jewell, MD, Nadeem R Abu-Rustum, MD, Carol L Brown, MD, Dennis S Chi, MD, Yukio Sonoda, MD, Douglas A
Levine, MD, Richard R Barakat, MD, Memorial Sloan-Kettering Cancer Center
P080 INTEGRATION AND TRAINING OF ROBOTICALLY-ASSISTED SURGERY IN A GYNECOLOGIC ONCOLOGY FELLOWSHIP PROGRAM Mario M
Leitao, MD, Ginger J Gardner, MD, Gabriel Briscoe, Kevin Santos, Elizabeth Jewell, MD, Carol L Brown, MD, Dennis S Chi, MD, Richard R Barakat, Memorial
Sloan-Kettering Cancer Center
P081 COLPOTERES SUSPENSION PROCEDURE John S Missanelli, DO, Grossmont Obstetrics and Gynecology
P082 INTRODUCTION OF ROBOTIC TECHNOLOGY FOR HYSTERECTOMY: ANALYSIS OF FEASIBILITY AND COMPLICATION RATES DURING
THE FIRST 4 YEARS OF USE Sidonia-Maria Saceanu, Resident Doctor, Nicola Pluchino, Dr, Letizia Freschi, Dr, Vito Cela, Dr, Marcela Goga, Dr, Lavinia
Dobrescu, Dr, Alexandru Goganau, Dr, Andrea Genazzani, Professor, Department of Reproductive Medicine and Child Development Division of Gynecology and
Obstetrics University of Pisa,Italy,Department of Gynecology and Obstetrics II, University Hospital Craiova,Romania
P083 ROBOTIC SURGICAL REMOVAL OF BLADDER ENDOMETRIOSIS -THE NEW GOLD STANDARD? Sidonia-Maria Saceanu, Dr, Nicola Pluchino,
Dr, Letizia Freschi, Dr, Alexandru Handabureac, Dr, Ayed Kamal, Dr, Alexandru Goganau, Dr, Vito Cela, Dr, Andrea Genazzani, Professor, Department of
Reproductive Medicine and Child Development Division of Gynecology and Obstetrics University of Pisa,Italy,Department of Gynecology and Obstetrics II,
University Hospital Craiova,Romania
P084 ROBOTIC ASSISTED LAPAROSCOPIC ABDOMINAL CERCLAGE: A NOVEL APPROACH Donna Brown, MD, Frank Craparo, MD, Mark Shahin, MD,
Larry Barmat, MD, Abington Memorial Hospital, Abington, PA
P085 ROBOT-ASSISTED VERSUS OPEN RADICAL HYSTERECTOMY: A COMPARISON OF ONE SURGEON’S OUTCOME. Bilal M Sert, MD, Vera Abeler,
MD PhD, The Norwegian Radium Hospital
P086 MORBID OBESITY OUTCOMES IN ROBOTIC GYNECOLOGIC SURGERY Taryn Gallo, MD, Masoud Azodi, MD, Yale New Haven Health/Bridgeport Hospital
P087 INCIDENCE OF VAGINAL CUFF DEHISCENCE WITH ROBOTIC HYSTERECTOMY: AN ANALYSIS OF 500 CASES Taryn Gallo, MD, Masoud Azodi,
MD, Yale New Haven Health / Bridgeport Hospital
P088 USE OF INTRAUTERINE MANIPULATOR AND ITS EFFECT ON LYMPHOVASCULAR SPACE INVASION IN ROBOTICALLY ASSISTED
ENDOMETRIAL CANCER STAGING Rhoda A Raji, MD, Karim ElSahwi, MD, Charlene Hooper, MD MPH, Elena Ratner, MD, Dan-Arin Silasi, MD, Peter E
Schwartz, MD, Thomas J Rutherford, MD PhD, Masoud Azodi, MD, Yale-New Haven Hospital, New Haven, CT, 06520 , USA.
P089 SINGLE PORT HYSTERECTOMY: CONVERTING FROM SINGLE PORT LAPAROSCOPY TO SINGLE PORT ROBOTIC: THE GREEK EXPERIENCE
OF INTRODUCING INNOVATIVE SURGERY IN A FINANCIAL CRISIS ENVIRONMENT STEFANOS CHANDAKAS, MD MBA PhD, JOHN ERIAN,
FRCOG, Iaso Group of Hospitals, Athens, Greece and Attikon University Hospital, Athens, Greece
P090 ENDOMETRIAL CANCER AND ROBOTIC SURGERY: OUR EXPERIENCE MARIO VILLA, MD, MICHELA TERUZZI, MD, CIRO SPORTELLI, MD,
FRANCESCA FEI, MD, GIOVANNA CASPANI, MD, SARA SACCO, MD, ANTONIO PELLEGRINO, MD, Azienda Ospedaliera Ospedale Provinciale di Lecco, Italy
P091 LAPAROSCOPIC AND ROBOTICALLY ASSISTED HYSTERECTOMY. OUR EXPERIENCE IN A SERIES OF 8 CONSECUTIVE CASES. Konstantinos
P Mirillas, MD, Petros C Hiridis, MD, Bisbikis Dimitris, MD, Savas C Hiridis, MD MSc, Perikles S Chrysocheris, MD, Konstantinos M Konstantinidis, MD PhD
FACS, Athens Medical Center
P092 ROBOTIC REPAIR AND REINFORCEMENT WITH PERMACOL® OF GIANT HIATAL HERNIA IN AN INFANT Eun Young Chang, MD, Jae Ho
Shin, MD, Hye Kyung Chang, MD PhD, Jung-Tak Oh, MD PhD, Seok Joo Han, MD PhD, Department of Pediatric Surgery, Severance Children’s Hospital, Yonsei
University College of Medicine, Seoul, Korea
P093 THE EXPERIENCE OF THE 2ND UROLOGY DEPARTMENT AT HYGEIA HOSPITAL IN ROBOTIC SURGERY ALEXANDROS MOKAKOS, MD,
SPIRIDON MARTINIS, MD, EMANUEL PANAGIOTOU, MD, 2nd Department of Urology, Hygeia Hospital, Athens Greece
P094 ROBOTIC-ASSISTED RADICAL PROSTATECTOMY IN MEN OVER 75 YEARS OF AGE. SURGICAL, ONCOLOGIC AND FUNCTIONAL
OUTCOMES. Apostolos P Labanaris, MD PhD, Vahudin Zugor, MD PhD, Jorn H Witt, MD PhD, Department of Urology and Pediatric Urology – Prostate Center
Northwest, St. Antonius Medical Center, Gronau, Germany
P095 EVALUATION OF SURGICAL MARGIN STATUS IN PATIENTS UNDERGOING ROBOTIC-ASSISTED RADICAL PROSTATECTOMY FOR LOW,
INTERMEDIATE, AND HIGH-RISK PROSTATE CANCER. Apostolos P Labanaris, MD PhD, Vahudin Zugor, MD PhD, Jorn H Witt, MD PhD, Department of
Urology and Pediatric Urology – Prostate Center Northwest, St. Antonius Medical Center, Gronau, Germany
P096 ROBOTIC RADICAL AND PARTIAL NEPHRECTOMY Nick Pardalidis, Nick Andriopoulos, Aggelos Karamanis, Eleni Kosmaoglou, Athens Medical
Centre, Athens, Greece
P097 RETROSPECTIVE STUDY ON ANATOMIC VARIATIONS OF RENAL VESSELS BASED ON LAPAROSCOPIC-ROBOTIC SURGERY EXPERIENCE
Chady Waked, MD, Ibrahim-Michel Karam, MD, cyril Perrenot, MD, Manuella Perez, MD, Pascal Eschwege, MDPhD, Michel Claudon, MDPhd, Jacques Hubert,
MDPhD, Department of Urology, Brabois Hospital, Nancy, France

www.mirasurgery.org 35
Poster Abstracts
P001: ROBOTICS ENABLES A MINIMALLY INVASIVE APPROACH TO Belsey fundoplasty. All patients underwent pre-operative manometry and 24 hour
RIGHT SIDED EPIPHRENIC DIVERTICULUM Barbara Tempesta, CRNP, pH study. The procedure was performed through five laparoscopic ports. The
Marc Margolus, MD, Eric Strother, CSA, Farid Gharagozloo, MD Washington hiatus was closed anteriorly and posteriorly. The esophagus was intussuscepted
Institute Of Thoracic And Cardiovascular Surgery; The George Washington into the stomach by 2 cm for 270 degrees. Results were assessed by preoperative
University Medical Center and postoperative endoscopy, manometry, 24 hour pH study, UGI study,
subjective symptom questionnaire, and objective Viscik grading.
Introduction: The surgical treatment of an epiphrenic diverticulum involves
resection of the diverticulum as well as a long esophageal myotomy. Although Results: Indications for surgery were intractability and pulmonary complications.
minimally invasive approaches have been used with left sided epiphrenic Median OR time was 3 hours. Median hospitalization was 1 day. Mean follow
diverticulum, the treatment of a right sided diverticulum has required a up was 36 months. Subjective symptomatic improvement decreased from 8.3
thoracotomy. The unique capabilities of the robot, specifically three dimensional +/- 0.6 to 0.7 +/- 0.2 (p<0.05). 95% were Viscick I. 23 patients (76%) had
visualization and greater maneuverability in a confined space, enables a transient postoperative dysphagia which resolved by the third postoperative
minimally invasive right sided approach to patients with a right esophageal week. At follow up there was no gas bloat or long term dysphagia and there was
diverticulum and single stage diverticulectomy and esophageal myotomy. no recurrence of hiatal hernia.
Methods: Over an 18 month period, 3 patients underwent robotic Conclusions: Robotic laparoscopic gastroesophageal valvuloplasty recreates the
diverticulectomy and esophageal myotomy through the right chest. Success normal anti-reflux barrier. This procedure is associated with a low incidence of
of the myotomy was judged by intra-operative EGD and post op esophagram. gas bloat and dysphagia. The results appear to be sustained in a medium term
Patients were scored symptomatically both subjectively by interview and follow up. Although greater experience is necessary, a robotic laparoscopic
objectively by Viscik classification of pre-op and post operative symptoms. gastroesophageal valvuloplasty may represent a more physiologic alternative to
Patients underwent rigorous follow up for recurrence of symptoms. the Nissen fundoplication.
Results: There were 2 women and I man, mean age 56 years. There was no P004: ROBOT-ASSISTED THORACOSCOPIC RIGHT UPPER
gastroesophageal reflux and all patients were judged to be Viscik I in the post- LOBECTOMY FOR EARLY STAGE LUNG CANCER - A VIDEO
op period. There was complete relief of dysphagia. There were no esophageal PRESENTATION OF ROBOT POSITIONING AND OPERATIVE
perforations. There was no recurrence of symptoms at a mean follow up of 12 TECHNIQUE Farid Gharagozloo, Marc Margolis, MD, Eric Strother,
months. Pre-operatively all patients had esophagitis. This esophagitis persisted CSA, Barbara Tempesta, CRNP Washington Institute Of Thoracic And
for a mean of 6 months in 2 patients with complete resolution. Post-operatively Cardiovascular Surgery; The George Washington University Medical Center
one patient underwent a laparoscopic cholecystectomy.
Objective: Robotic surgical systems have the potential to enhance thoracoscopic
Conclusion: Robotics obviates the need for an open surgical approach in this lobectomy by facilitating complex 3-D maneuvers and fine dissection. This
subset of patients with right sided epiphrenic diverticulum and is associated with video illustrates the use of the da Vinci surgical robot for thoracoscopic right
excellent results. upper lobectomy in patients with early stage lung cancer.
P002: ROBOTIC APPROACH TO A LEFT SIDED EPIPHRENIC Methods: This patient underwent a robot assisted video-assisted right upper
DIVERTICULUM Farid Gharagozloo, Marc Margolis, MD, Eric Strother, lobectomy and complete mediastinal nodal dissection for early stage lung cancer.
CSA, Barbara Tempesta, CRNP Washington Institute Of Thoracic And Conclusion: Robotics enables minimally invasive anatomic lobectomy comparable
Cardiovascular Surgery; The George Washington University Medical Center in technique to lobectomy by thoracotomy. Robotic lobectomy is associated
Introduction: Non-robotic minimally invasive approaches, either by laparoscopy with low morbidity and mortality. Low local recurrence rate and pathologic
or thoracoscopy, in patients with a left sided epiphrenic diverticulum is upstaging may be due to enhanced visualization and more accurate and extensive
associated with complications related to esophageal perforation and the success mediastinal and hilar nodal dissection afforded by the robot. The results
of the myotomy. A left thoracic approach is preferable to a trans-abdominal improve significantly with greater experience.
approach in these patients. Robotics enables a minimally invasive trans-thoracic
approach to diverticulectomy and distal esophageal myotomy in patients with P005: DECREASED POST-OPERATIVE PAIN WITH A NOVEL PORT
left sided diverticuli. CLOSURE IN THORACIC ROBOTIC SURGERY Eric Strother, CSA, Marc
Margolis, MD, Barbara Tempesta, CRNP, Farid Gharagozloo, MD Washington
Methods: We present a video of such an approach in a 44 year old female Institute Of Thoracic And Cardiovascular Surgery; The George Washington
with an epiphrenic diverticulum. The patient underwent robotic left sided University Medical Center
diverticulectomy and distal esophageal myotomy.
Introduction: Postoperative pain relief is paramount for decreasing
Results: There was excellent relief of dysphagia and no gastroesophageal reflux. complications after thoracic surgery. Although a number of techniques are
The post-operative course was complicated by a pulmonary embolus and used for relief of pain following video assisted and robotic thoracic surgery,
collapse of the left lower lobe, both of which responded to conventional therapy. post operative pain remains a significant consideration. After minimally
Conclusion: Intermediate term follow up by interview and an esophagram invasive thoracic surgery, the soft tissues are re-approximated at the entry
revealed a normal esophagus with easy passage of contrast through the sites. However, traditionally the intercostal space is not re-approximated.
gastroesophageal junction. As rib movement and intercostal nerve stimulation has been shown to be a
significant component of post thoracotomy pain syndrome, we hypothesize
P003: ROBOTIC LAPAROSCOPIC GASTROESOPHAGEAL that re-approximation of the intercostal space and rib fixation may decrease
VALVULOPLASTY FOR THE TREATMENT OF GASTROESOPHAGEAL pain following video assisted and robotic thoracic surgery.
REFLUX DISEASE Farid Gharagozloo, MD, Eric q Strother, CSA, Marc
Methods: Over 6 months, 50 patients underwent rib re-approximation (RA) at
Margolis, MD, Barbara Tempesta, CRNP Washington Institute Of Thoracic And
the time of minimally invasive thoracic surgery. At each of the entry sites, the
Cardiovascular Surgery; The George Washington University Medical Center
rib above and below the intercostal entry site was drilled. A number 3 vicryl
Objective: The Nissen fundoplication is the most common procedure performed suture was passed and tied thereby reapproximating the ribs and closing the
for gastroesophageal reflux disease. The Nissen procedure wraps the fundus of intercostal space. Efficacy of post operative pain control was evaluated in terms
the stomach around the distal esophagus and is associated with dysphagia and of a Likert pain scale ranking, length of stay, and return to activities of daily
gas bloat in a subset of patients. The normal antireflux barrier consists of a valve living. The data was collected prospectively and evaluated retrospectively. This
which is formed by the intussusception of the esophagus into the stomach at the surgical cohort was then compared to a similar group of patients who underwent
gastroesophageal (GE) junction. Creation of a gastroesophageal valve using the closure without rib approximation after minimally invasive thoracic surgery
surgical robot may enable a more physiologic anti-reflux procedure associated (control, C).
with lower incidence of dysphagia and gas bloat.
Results: Post-operative Likert pain scale on POD 1, 14, and 30 was 6, 4, and 1.5
Methods: During a 52 month period, 30 patients (11 men, 19 women, mean age 47 for RA versus 7.7, 6.8, 4.0 for C. Median length of stay was 3 days for RA, 4 for
years) with gastroesophageal reflux disease underwent robot-assisted laparoscopic C. Return to normal activities was decreased by 20% between the two cohorts.
36 6 TH ANNUAL MIRA CONGRESS May 11-13, 2011
Conclusion: Rib approximation after video assisted and robotic surgery is associated P008: ROBOTIC ASSISTED THORACOSCOPIC RESECTION OF
with decreased pain and earlier return to normal activities. Although greater BRONCHOGENIC CYSTS Farid Gharagozloo, MD, Barbara Tempesta, CRNP,
experience is necessary, rib approximation as part of the routine closure of port sites Eric Strother, CSA, Marc Margolis, MD Washington Institute Of Thoracic And
should be considered in all patients undergoing minimally invasive thoracic surgery. Cardiovascular Surgery; The George Washington University Medical Center
Objectives: Bronchogenic cysts are usually adherent to adjacent structures which
P006: ROBOTIC SEGMENTECTOMY OF EARLY STAGE LUNG CANCER
makes a complete resection by conventional thoracoscopy difficult. The 3-D
Farid Gharagozloo, Marc Margolis, MD, Eric Strother, CSA, Barbara Tempesta,
visualization, greater instrument maneuverability, and more accurate dissection
CRNP Washington Institute Of Thoracic And Cardiovascular Surgery; The
of robotic surgical systems are ideally suited for the thoracoscopic resection of
George Washington University Medical Center
mediastinal bronchogenic cysts.
Introduction: Anatomic segmentectomy has been advocated as a curative
Methods: From 1/07 – 12/10 15 patients underwent robotic resection of a
procedure in selected patients with non-small cell lung cancer. We investigated
bronchogenic cyst. There were 9 women and 6 men. The robotic approach
the feasibility and suitability of robotic video assisted thoracoscopic
was from the right pleural space in 10 patients (67%) and from the left in 5
segmentectomy and complete mediastinal exeneration as a less invasive
patients (33%). Mean length of stay was 4 days. There was no conversion to a
alternative to the open procedure. Robotic anatomic segmentectomy and
thoracotomy.
complete mediastinal exeneration was performed in patients with impaired lung
function and small periphery located tumors. Conclusions: Robotic surgery is highly suited for resection of bronchogenic cysts
as it allows for a more accurate thoracoscopic dissection of the cysts away from
Methods: We performed a retrospective review of 48 patients who underwent
the surrounding structures.
robotic video assisted thoracic surgery segmentectomy for early stage lung cancer
in a 60 month period at our institution. All patients underwent robotic dissection P009: ROBOTIC RELIEF TO THE MEDIAN ARCUATE SYNDROME Farid
of the artery, vein, and the bronchus with division of the respective segmental Gharagozloo, MD, Marc Margolis, MD, Eric Strother, CSA, Barbara Tempesta,
structures. In addition a complete mediastinal nodal exeneration was performed CRNP Washington Institute Of Thoracic And Cardiovascular Surgery; The
with removal of subcarinal, paraesophageal, paratracheal, and inferior pulmonary George Washington University Medical Center
ligament lymph nodes. Inclusion criteria was a pre-operative clinical T1 disease in
a patient with impaired pulmonary function (FEV1 < 800 or DLCO < 50). Introduction: The median arcuate ligament syndrome is a rare disorder which
results from compression of the celiac artery by aberrant diaphragmatic
Results: There were 26 men, 22 women, mean age 74 years. All patients underwent muscular or fibrous bands. The syndrome is characterized by post prandial
R0 resection. Operating room time was 3 hours, no statistical difference between abdominal pain, nausea, vomiting and weight loss. Surgical management has
robotic segmentectomy and robotic lobectomy. Median hospital length of stay was 6 included complete division of the median arcuate ligament. This procedure
days. All patients underwent segmentectomy for early stage lung cancer. Histology has been performed by laparotomy and laparoscopy. We hypothesized that a
was squamous cell (11 patients), adenocarcinoma (20 pts), adenosquamous (9), robotic laparoscopic approach would be superior by virtue of three dimensional
basaloid (1), giant cell (2), and bronchoalveolar (5). Tumor size 2.0 cm or less was visualization and greater instrument maneuverability at the point of surgery.
25 patients, 23 were > 2.0 cm. Complications included atrial fibrillation, atelectasis
requiring bronchoscopy, and C-Doff infection. There were no mortalities. Methods: A 24 year old female with history of post prandial abdominal pain,
nausea, and vomiting underwent robotic laparoscopic division of the arcuate
Conclusions; Robotic video assisted segmentectomy is a safe procedure which may ligament. The syndrome was diagnosed by pre-operative computer tomography,
represent a less invasive oncologic procedure to patients with small lung cancers MRI, angiography, which demonstrated extrinsic compression at the origin of
and limited cardiopulmonary reserve. the celiac artery. Five laparoscopic trocars were used. The celiac artery and
branch vessels were completely skeletanized. The compression of the celiac
P007: ROBOTIC SURAL NERVE GRAFT FOR REVERSAL OF THORACIC
artery appeared to result from an elongation of the left limb of the esophageal
SYMPATHECTOMY Farid Gharagozloo, Marc Margolis, MD, Eric Strother,
crus of the diaphragm.
CSA, Barbara Tempesta, CRNP Washington Institute Of Thoracic And
Cardiovascular Surgery; The George Washington University Medical Center Results: Post op course was uncomplicated. A post operative CT scan demonstrated
no residual stenosis. The patient’s symptoms improved dramatically in the
Title: Robotic video assisted reconstruction of the sympatheti chain for reversal
immediate post operative period. Post prandial abdominal pain resolved
of compensatory hyperhydorsis after sympathectomy.
immediately after surgery but nausea persisted an additional 4 months.
Introduction: Compensatory hyperhydrosis after thoracic dorsal sympathectomy
Conclusion: Robotic surgical systems present a significant technological advance
is a common recongnized complication. Sympathetic chain reconstrcution
to conventional laparoscopic instruments. This advance is most notable in the
using peripheral nerve grafts has been advocated as a means of reversing
management of patients with median arcuate ligament syndrome who require
debilitating compensatory hyperhydrosis. Improvements after reconstruction
highly accurate instrument movement and three dimensional visualization in a
have been reported to a variable extent. The best results have been obtained by
very confined space.
thoracotomy and nerve grafting using an operating microscope. We reasoned
that the magnified three dimensioanl high definition visualization possible with P010: SUBPLEURAL CATHETER PLACEMENT FOR POST-OPERATIVE
the robotic systems and the superb instrument maneuverability can enable nerve PAIN - TECHNIQUE AND INTERMEDIATE TERM RESULTS Barbara
grafting using the robot and minimally invasive techniques, thereby obviatring Tempesta, CRNP, Marc Margolis, MD, Eric Strother, CSA, Farid Gharagozloo,
the complications associated with a thoracotomy. MD Washington Institute Of Thoracic And Cardiovascular Surgery; The
Methods/Results: A 26 year old female who had undergone throracsocopic George Washington University Medical Center
bilateral sympathectomy for primary hyperhydrosis presented with severe Objectives: Postoperative pain relief is paramount for decreasing complications
compensatory hyperhydosis afffecting the lower chest, abdomen, and lower after thoracic surgery. Systemic narcotics and epidurals provide excellent relief
extremities. The patient underwent a right trans thoracic robotic pocedure but are hampered by complications such as somnolence, insertion and infusion
using three non trocar 2 cm incisions. Sural nerve was harvested from the left side effects, and return of pain after removal. Direct prolonged intercostal
lower extremity. The sympathetic chain was dissected, the proximal portion pain relief with continuous infusion of local anesthetic is an alternative to
was identified just above the second sympathetic ganglion and the distal [portion conventional pain relief techniques.
was identified just below the fourth sympathetic ganglion. The interposition
sural nerve graft wa sutured in place using the robot with 5-0 non-absorbablke Methods: Over a 62 month period 300 patients who underwent thoracic surgery
suture. The pleural space was drained. The patient was hospitalized for 4 days. underwent this technique for subpleural infusion of a local anesthetic via a
The immediate post operative course was uncomplicated. specially created subpleural tunnel where two five inch catheters are inserted,
covering intercostal spaces two through eight. 0.25% Bupivicaine is infused
Conclusion: Robotic interposition of a sural nerve graft is feasible for the at 2cc/hr via each catheter for a ten day duration. Efficacy of pain control was
reconstruction of the sympathetic chain in patients with compensatory evaluated in terms of a Likert pain scale ranking as well as length of stay and
hyperhydrosis after sympathectomy. This technique replicates the most return to activities of daily living.
commonly performed procedure which has hereto required a thoracotomy.
www.mirasurgery.org 37
Poster Abstracts
Results: Post-operative pain ranked on post-op day 1, 14 and 30 was 7.7, 6.8, and average LIMA harvesting and anastomosis times were 31.3 ± 10.5 (18~55)
4.0 respectively for the control group and 5.0, 3, and 1 for the study group; all p min and 11.3 ± 4.7 (5~21) min respectively. The mean operating room
< 0.05. Median length of stay was 4 days and median return to normal activities and operation times were 336.1 ± 58.5 (210~580) min and 264.8 ± 65.6
was 17 days. Incidence of long term pain syndrome was less than 3%. (150~420) min respectively. The drainage was 164.9 ± 83.2 (70~450) ml.
Before discharge, 50 patients underwent angiography and 8 patients underwent
Conclusions: Prolonged subpleural catheter infusion of local anesthetic with
CTA scan, and the study showed that graft patency was 100% and unexpectedly,
a system devised for outpatient use may represent a superior pain control
LIMA graft developed a collateral branch in 2 patients. After discharge, all
technique with greater patient satisfaction and shorter hospitalization and lower
patients were followed up by CTA scan, average follow-up time was 12.67±9.43
incidence of post thoracotomy pain syndrome.
(1 to 40 months). One patient had gastric bleeding after surgery.
P011: PROLONGED OPERATIVE TIME IN ROBOTIC TOTALLY Conclusions: BH TECAB is a safe procedure in selected patients and produces
ENDOSCOPIC TOTALLY ENDOSCOPIC COR ONARY BYPASS SURGERY excellent early and midterm patency of anastomosis.
- IS IT AN ISSUE? Dominik Wiedemann, Nikolaos Bonaros, Thomas Schachner,
Felix Weidinger, Eric Lehr, Mark Vesely, Guy Friedrich, Johannes Bonatti 1 P013: ROBOTIC TOTALLY ENDOSCOPIC CORONARY ARTERY BYPASS
University Clinic of Cardiac Surgery, Innsbruck Medical University, Austria 2 GRAFTING FOR SPONTANEOUS CORONARY ARTERY DISSECTION
Division of Cardiac Surgery, Department of Surgery, University of Maryland, Brody Wehman, MD, Eric Lehr, MD PhD, Ratnakar Mukherjee, MD, Alina
USA 3 Division of Cardiology, University of Maryland, USA 4 Department of Grigore, MD, Bartley Griffith, MD, Johannes Bonatti, MD University of
Cardiology, Innsbruck M Maryland Medical Center
Introduction: Robotically assisted Totally Endoscopic Coronary Artery Bypass Objective. Spontaneous coronary artery dissection (SCAD) is a rare but
Grafting (TECAB) is the only viable option to perform endoscopic coronary potentially life-threatening cause of acute coronary syndrome known to affect
surgery. TECAB is requires learning curves and long operative times. The young adults without coronary artery disease risk factors. Management of
aim of this study was to evaluate the effect of longer operation times on the SCAD may demand coronary bypass surgery depending on the location of the
perioperative outcome of patients undergoing TECAB. dissection and clinical presentation. Robotic totally endoscopic coronary artery
bypass grafting (TECAB) for SCAD has not been reported.
Patients & Methods: From 2001 to 2009 A total of 325 consecutive patients
underwent TECAB Correlations between operation times with preoperative, Methods. A 58 year old male patient presented with acute chest pain while being
intra-operative and early postoperative parameters were investigated ROC evaluated for acute cholecystitis. On coronary angiography he was found to
analysis was used to define the threshold of the procedure duration above have a dissection of the middle portion of his left anterior descending (LAD)
which longer a Intensive Care Unit (ICU) stay and ventilation time was needed. artery. A ventriculogram showed decreased anterior wall motion and surgical
Demographic data, intra- and postoperative parameters as well as survival data revascularization was indicated. A prophylactic intraaortic balloon pump was
of patients with and without prolonged operation times were compared and risk placed. Totally endoscopic coronary artery bypass grafting was performed using
factors for prolonged operation times were identified. the da Vinci surgical robot, the left internal mammary artery was harvested and
sutured to the LAD.
Results: Patients with prolonged operation times had more often endoscopic
multivessel revascularzation (p<0.001) and underwent beating heart TECAB Results. The anastomosis was performed in a dissection free distal portion of
more often (p=0.023). Other preoperative parameters such as EuroScore, the LAD. An on table angiogram showed a patent graft and an expanded true
Body Mass index, age, gender, ejection fraction, NYHA-stadium, serum- lumen of the dissected LAD with adequate antegrade and retrograde filling. The
creatinine were not associated with longer operative times. . The incidences of postoperative course was uncomplicated and the patient was discharged to home
intraoperative technical difficulties and conversions (p<0.001) were higher in on postoperative day five. At one month following the operation, the patient was
the group of patients with longer operation times. Longer operation times were asymptomatic and had returned to his baseline activity level without need for
associated with prolonged ICU-stay, mechanical ventilation times, hospital stay sternal precautions.
and requirement of PRBC and FFP’s . ROC analysis showed that operation times Conclusions: We describe a first successful case of completely endoscopic
>445 min and >478min predicts prolonged ICU stay (>48h) and mechanical coronary surgery using the da Vinci system in a patient with SCAD and acute
ventilation time (>48h) respectively. Additionally, patients with a procedure anterior wall ischemia. The case demonstrates that TECAB can be carried out in
duration >478 min had a longer hospital stay, higher rates of renal failure, difficult subsets of patients undergoing coronary bypass grafting.
pneumonia, superficial wound infections, sepsis, and hospital mortality. Kaplan-
Meier analysis revealed decreased survival rates in patients with operation times P014: ROBOTIC APPROACH TO GIANT HIATAL HERNIAS WITH
>477.5 min (98.8% vs. 93.8%, p=0.02) at a median follow up of 20 months PRIMARY REPAIR OF THE DIAPHRAGMATIC HERNIA Sigrid Bairdain,
(0-96). MD, Marc Margolis, MD, Barbara Tempesta, CRNP, Eric Strother, CSA,
Conclusion: Multivessel disease and conversion TECAB are independently Farid Gharagozloo, MD Washington Institute of Thoracic and Cardiovascular
associated with longer operative times. Longer operation times significantly Surgery; The George Washington University Medical Center
influence early postoperative outcome variables after TECAB. Intraoperative Introduction: Giant hiatal hernias with intrathoracic stomach have not been
technical difficulties and conversion to sternotomy as well as lower mid-term amenable to repair using laparoscopy. Conventionally the surgical approach to
survival were associated with longer operation times. Patients with shorter OR- these large hernias has been through a thoracotomy or laparotomy or the use of
times had survival benefits. a hiatal patch with laparoscopy. Historically, independent of the approach, the
results of surgical repair have been disappointing. By virtue of three dimensional
P012: EARLY AND MIDTERM RESULTS OF TOTALLY ENDOSCOPIC visualization and greater effector instrument maneuverability, the robot can
CORONARY ARTERY BYPASS GRAFTING ON BEATING HEART allow for a laparoscopic approach for the dissection of the intrathoracic stomach
Changqing Gao, MD PLA General Hospital and primary repair of the giant hiatal hernia.
Objectives: Despite the early introduction of totally endoscopic coronary artery Methods: In a 10 month period, 5 patients with an intrathoracic upside down
bypass on beating heart (BH TECAB), only a limited number of cases have stomach and a giant hiatal hernia underwent a robotic laparoscopic approach.
been performed. The limiting factor has been the concern about safety and The robot was introduced through 4 trocars. The intra thoracic dissection of the
graft patency of the anastomosis. This study describes our experience with BH hernia sac and the stomach was performed robotically. The right and left crus were
TECAB with robotic assistance and its early and midterm results. dissected, hiatal closure was performed primarily using 0 Ethibond suture with
Methods: In 365 cases of robotic cardiac operations, 162 patients underwent pledgets of vicryl mesh. A concomitant anti-reflux procedure was performed in all
robotic CABG on beating heart, in which 60 patients (46/M, 14/F) underwent patients. The success of the procedure was assessed by intra-operative endoscopy,
BH TECAB. Mean age was 56.97 ± 9.7 (33 to 77) years. LIMA to LAD post-operative esophagram. Subjective symptoms were assessed by a symptom
anastomosis was performed using U-Clip. interview. Objective symptoms were assessed by third party Viscik grading.
Results: 58 TECAB procedures were completed, in which 16 patients received Results: There were 2 men, 3 women, mean age 56 years. The procedure was
hybrid procedures. Two patients were converted to minithoracotomy. The assessed to be successful in all patients based on endoscopy and esophagram. All
38 6 TH ANNUAL MIRA CONGRESS May 11-13, 2011
patients were asymptomatic and were graded as Viscik I at 1 day, 2 weeks, and (p<0.001) and body weight (p=0.003) were the only predictors found to be
10 months. There was no recurrence of hiatal hernia. significant in multivariate analysis. Hospital mortality was 1.7% (1/59) in the
group of patients with atrial fibrillation and 0.6% (2/325) in the group that
Conclusions: Robotics enables a complete dissection of the hernia sac and
showed no AFib after operation (p=n.s.). Hospital stay was 7 (4-54) days in
reduction of intrathoracic stomach in patients with giant hiatal hernias.
patients with AFib and 6 (2-33) days in patients without AFib (p=n.s.). There
Although greater experience is necessary, robotics may represent a more viable
was no significant 5 year survival difference in patients with and without
minimally invasive approach with primary closure of the hiatus in patients with
postoperative Afib (95.8% vs. 94.5%, p=n.s.).
giant hiatal hernias.
Conclusion: We conclude that the incidence of postoperative AFib in TECAB
P015: SHORT-TERM ANGIOGRAPHIC RESULTS OF ROBOTICALLY is relatively low. Age and body weight are the most important predictors
ASSISTED CORONARY ANASTOMOSIS USING CONVENTIONAL AND of postoperative AFib following TECAB. Short term clinical outcome
CT-ANGIOGRAPHY Nikolaos Bonaros, MD, Felix Weidinger, MD, Benedikt and intermediate term survival are similar in patients with and without
Hofauer, MD, Gudrun Feuchtner, MD, Fabian Plank, Guy Friedrich, MD, Eric postoperative AFib.
Lehr, MD, Johannes Bonatti, MD, Thomas Schachner, Md Department iof
Cardiac Surgery, Innsbruck Medical University P017: A COMPARATIVE STUDY ON ROBOTIC VERSUS OPEN RIGHT
HEMICOLECTOMY FOR CANCER F. Luca, MD, M. Valvo, MD, S.
Background: Robotic technology enables totally endoscopic coronary artery
Cenciarelli, MD, T. Leal Ghezzi, MD, M. Zuccaro, MD, S. Pozzi, MD, R. Biffi,
bypass grafting on the arrested or on the beating heart. The aim of the study
MD Division of Abdomino-Pelvic Surgery, European Institute of Oncology;
was to investigate the short-term quality of robotically sutured anastomoses by
Milan, Italy
means of invasive graft angiography and multi-detector CT angiography.
Introduction: Open right hemicolectomy has traditionally been considered as the
Methods: Two hundred seventy six patients received robotically sutured coronary
standard procedure for right-sided colonic tumors. The main objective of colon
anastomoses using the daVinci telemanipulation system. 140 (51%) and 264
cancer surgery is the removal of the primary tumor with an adequate number
(96%) underwent postoperative conventional graft angiography and CT
of locoregional lymph nodes and surgical margin. The aim of our study was to
angiography respectively. The vast majority of the patients underwent single
compare the surgical and pathological outcomes of patients with right-sided
or double arrested heart TECAB (207/276), 21 patients had a BH TECAB,
colon cancers operated on by means of open and robotic surgery.
12 and 3 patients received a sequential or Y-grafting respectively. 48 patients
underwent robotically sutured anastomosis through conventional sternotomy. Methods & Procedures: 33 consecutive patients who underwent robotic right
hemicolectomy due to right-sided colon cancer from February 2008 were
Results: The median interval from surgery to coronary angiography was 3
retrospectively well matched with 102 patients operated on by open approach
months (0.25-72 months). The median interval to CT angiography was also 3
from July 1994 to December 2002. Pathological and postoperative data were
months (0.25-8 months). 160 /319 (50%) robotically sutured anastomoses were
included in a dedicated database and analyzed.
evaluated by conventional graft angiography. There were 3 anastomoses with
a non-significant angiographic stenosis, 2 anastomoses with a relevant stenosis Results: mean operative time was longer in the robotic group (p < 0.001), 191.7
>50%, 1 anastomotic occlusion, and 1 anastomosis to an incorrect target min (134 – 250) versus 136.2 (45 – 240) min in the open group. Estimated
vessel. CT angiography revealed 1 anastomotic stenosis, 2 grafts with a string intraoperative blood loss was lower in the robotic group: 6.1 ml versus 94.8 ml
phenomenon as a result of competitive flow, 3 graft occlusions and one incorrect (p < 0.001). Intra- and post-operative blood transfusions were more frequent
grafting site. In 153/160 (96%) anastomoses evaluated by invasive angiography in the open group. Despite the similar number of lymph nodes retrieved in
a perfect result was detected. Accordingly CT angiography revealed a perfect both groups At least 15 or more lymph nodes were found in the specimen in 90
postoperative result in 298/305 evaluated anastomoses (98%). CT angiography out of 102 patients (88.2%) treated by means of the open technique versus 33
could very well detect relevant angiographic stenosis, graft occlusion and patients (100%) in the robotic group (p = 0.038). The median postoperative
incorrect target vessel anastomosis in all cases. hospital stay was shorter in the robotic group, 5 versus 8 days (p < 0.001).
Although not statistically significant, an inferior percentage of infectious and
Conclusions: Robotically sutured anastomosis on the arrested or on the beating
overall postoperative complications was observed among patients undergone
heart, as well as robotically-assisted composite grafting can be performed with
a robotic procedure. Three patients of the open group were reoperated due to
satisfying angiographic results. CT angiography can be used as an alternative for
postoperative surgical complications, while no reintervention was needed in the
postoperative evaluation of relevant anastomotic dysfunction.
robotic group. No mortality was reported in both groups.
P016: CAUSES AND CONSEQUENCES OF POSTOPERATIVE ATRIAL Conclusions: robotic right hemicolectomy is an oncologically safe and effective
FIBRILLATION IN TOTALLY ENDOSCOPIC CORONARY BYPASS procedure. The number of lymph nodes retrieved in the robotic group compared
SURGERY Felix Weidinger, MD, Thomas Schachner, MD, Nikolaos Bonaros, to the open group of our series was more homogeneous and none of the patients
MD, Benedikt Hofauer, Eric J Lehr, MD, Mark Vesely, MD, David Zimrin, operated on with robotic technique had a suboptimal lymphadenectomy. Further
MD, Johannes O Bonatti, MD Innsbruck Medical University, Department of clinical trials are needed to confirm current evidence and determine whether
Cardiac Surgery; University of Maryland Medical Center, Division of Cardiac this can influence the prognosis. Robotics are likely to improve the as yet
Surgery poor adoption of minimally invasive surgery for colon cancer, estimated to be
Background: Postoperative atrial fibrillation (AFib) is the most common between 6 and 12 % in western countries.
complication in patients undergoing coronary artery bypass grafting. Little
P018: THE LEARNING CURVE IN RECTAL RESECTION: IS IT FASTER IN
information concerning AFib following minimaly invasive cardiac surgery
ROBOTICS THAN IN LAPAROSCOPY? Olivia Sgarbura, MD PhD, Serban
is available. The aim of our study was to evaluate the incidence of AFib after
Vasile, MD, Mihai Eftimie, MD, Irinel Popescu, MD PhD FACS Fundeni
totally endoscopic coronary artery bypass grafting (TECAB) and to investigate
Institute of Digestive Diseases and Liver Transplantation, Bucharest, Romania;
factors influencing its occurrence.
University of Medicine and Pharmacy, Bucharest, Romania
Methods: Between 2001 and 2010 we performed TECAB in 384 patients, 73%
Introduction: Robotic surgery has become an important approach in rectal cancer
male, aged 60 (37-90). Single vessel bypasses were performed in 280 patients,
while we were still waiting for the high level evidence concerning laparoscopic
and 104 received multivessel coronary revascularisation. Procedures were
rectal resections. One of the features frequently evoked as an advantage for robotic
performed without cardiopulmonary bypass in 80 cases and 164 patients
surgery is the fast learning curve but current evidence is limited to the assessment
underwent a hybrid-intervention.
of the learning curve in robotic rectal resections. Our endpoint was to establish a
Results: A total of 59 patients (15.4%) developed AFib after TECAB. Univariate relation between the learning curves in the two minimally invasive approaches.
analysis showed hypertension (p=0.005), and increased age (p=0.007), body
Material & Methods: A series of 89 consecutive patients with laparoscopic rectal
weight (p=0.006), body mass index (p=0.005), EuroSCORE (p=0.035), and
resections, operated between 1995-2010, and a series of 44 consecutive patients
total TECAB operation time (p=0.01) to be significantly associated with atrial
with robotic rectal resections, operated between 2008-2010, were analyzed.
fibrillation. We also found an increased incidence of AFib in patients undergoing
The interventions were performed for rectal adenocarcinoma and included low
hybrid interventions (p=0.036) and beating heart TECAB (p=0.003). Age
www.mirasurgery.org 39
Poster Abstracts
anterior resections and abdominoperineal resections. Demographic data, total ureteral injury and subcutaneous emphysema) while 2 of 35 robotic cases were
time and type of operation were recorded for all cases. Total time, console time converted to laparoscopy (continuous air leak at camera port site). Utilizing
and docking time were recorded for robotic surgery. The results were analyzed unpaired t-test, we compared median values for length of stay (L-4.5, R-5 days; p=
with SPPS 15.0 (Spss Inc.) based on raw data plotted by chronological cases and 0.25), estimated blood loss (L-250cc vs R-125cc; p= 0.07), operative time (L-276
cumulative sum analysis. min vs R-309 min; p= 0.20) and lymph node harvest (L-18.5 vs R-18; p= 0.09);
there was no significant difference in the four categories among these four groups.
Results: The mean operating time was for 174 +/- 50 min for laparoscopy and
225+/-41 min for robotic surgery (p<0.001).Three phases were identified for Conclusions: Our retrospective review demonstrates no significant difference
laparoscopic resections and only two for robotic resections. The first 20 cases between robotic and laparoscopic colectomies comparing length of stay,
were the initial learning curve, the following 25 cases were the increasing estimated blood loss, operative time and lymph node harvest. Our data suggests
competence phase and the third phase consisting in 44 cases was the plateau robotic surgery is as safe as laparoscopy in experienced hands, and is an
indicating achieved competence. In robotics, the first 20 cases represented the acceptable modality for all types of colon resection.
learning curve but the following 24 cases indicated a plateau similar with the
third phase of laparoscopy. P021: LESSONS LEARNT FROM INTRODUCTION OF ROBOTIC
COLORECTAL SURGERY IN A SPANISH UNIVERSITY HOSPITAL Elena
Conclusions: The mastery of the robotic resection appears to be achieved after Ortiz-Oshiro, MD PhD, Angel Ramos Carrasco, MD PhD, Cristina Pardo
the first 20 cases, earlier than in laparoscopy. However a long term study is Martinez, MD PhD, Iris Sanchez Egido, PhD, Jaime González Taranco, PhD,
needed in order to assess a possible third phase in robotic resections that was not Jesus Alvarez Fernández-Represa, MD PhD Hospital Clinico San Carlos -
observed due to the low volume of cases. Universidad Complutense de Madrid
P019: ROBOTIC SURGICAL REMOVAL FOR RECURRENT PELVIC Introduction: Robotic colorectal surgery is currently gaining more and more
TUMOR AFTER COLON CANCER RESECTION Sorin Paun, PhD, Roxana acceptance throughout the world due to their advantages respecting to
Ganescu, MD, I Negoi, MD, Mihaela Burtea, MD, M Beuran, PhD Emergency traditional laparoscopic approach (highly precise dissection, 3D vision,
Hospital - Bucharest, Romania multiarticulated instruments, great performance in complex cases and
suturing). Groups performing robotic colorectal procedures are learning
Colon cancer, pelvis, recurrent tumor and surgical reintervention represent
progressively to overcome the handicaps of Da Vinci system, as loss of haptic
challenges for actual robotic surgery. We are still in the time of beginning of
feedback and the need of approaching 2-3 fields along the intervention. Our aim
the robotic surgery and maybe some of the gold indications for such a surgical
is to present the evolution of our learning in robotic colorectal surgery, through
technique could come from this area of medical interest.
analysis of techniques and outcomes.
This was the reason for us to operate a young female patient, 24 years old, one
Material & Methods: From out of 281 robotic digestive procedures performed in
year after a sigmoidectomy for well-differentiated adenocarcinoma T2N1M0G2
257 patients from July 2006 to December 2010, we have analysed colorectal
– a recurrent 2 cm diameter tumor was diagnosed in the pelvic-subperitoneal
ones: indications, surgical procedures (technique, intraoperative results) and
space right-side from the middle rectum. A transperitoneal robotic approach
postoperative outcomes, to reflect on our learning process.
was performed at that time and the tumor was removed along with the abscess
nearby it. No intraoperative problems were encountered (easier adhesiolisys was Results: 2006 2007 2008 2009 2010 Hartman reversal 1 2 1 - - Right
performed with robotic instruments) as well as no postoperative complications. hemicolectomy 1 11 7 2 1 Left hemicolectomy 2 17 7 4 - (L) Ant Rec Resect
6 months after this robotic procedure, the patient developed another 2.5 cm - 1 1 4 10 72 colorectal procedures have been performed in our institution in
diameter recurrent tumor but with other localization – intraperitoneal lateral the mentioned period with four-arms standard Da Vinci system. The surgical
superior to the colorectal anastomosis, 30 cm for the previous recurrent tumor team comprised three surgeons, anesthesiologist and expert nurses. Indications
removed by robotic procedure. For the late situation, an open laparotomy was evolved from benign to malignant cases and from right and left colectomies to
performed to remove the new tumor. rectal surgery. Time needed to setup the robot and docking, as well as time
needed to perform the procedures shortened with experience. There were no
Was the robotic approach the reason for the second tumor recurrence? Is it safe
conversion to laparoscopy, but 10 cases were converted to open (16.6%), mostly
to perform a robotic reintervention for colonic cancer? Obviously, pelvis is a
due to technical drawbacks. Lack of feedback resulted in colonic perforation in
space to be approached by robotic device because of the maneuverability of the
one case in the beginning. No other intraoperative incidents may be attributed
instruments and enhanced view over the operating field – a video can proved it.
to robotic approach. Pathologic outcomes in oncologic cases did not differ from
P020: ROBOTIC VERSUS LAPAROSCOPIC COLON AND RECTAL those obtained in open procedures. 3 anastomotic leaks occurred after rectal
SURGERY: EARLY COMPARISONS. Grace Montenegro, MD, Rami surgery (18.75%): two cases were managed conservatively (protective colostomy
Makhoul, MD, Vincent Obias, MD George Washington University in very low anterior resection) and one needed reintervention.

Introduction: Robotic colon and rectal surgery is a newly evolving field which Conclusions: From this initial experience in robotic colorectal surgery we have
has gained recent interest. Due to the superb visualization, dissection, and learnt that: - Laparoscopic previous experience is advisable - A stable and
increased degrees of freedom, robotic surgery is being applied to a variety of expert team is essential - Good indications, adequate selection of patients and
colon and rectal procedures. This study explores the initial experience in both application of planned protocols are the basis of success
laparoscopic and robotic colectomy of a recent minimally invasive colorectal
P022: ROBOTIC COLECTOMIES: A SERIES OF 122 CASES Francesca
surgery fellowship graduate.
Bazzocchi, MD, Domenico Garcea, MD, Andrea Avanzolini, MD, Barbara
Methods: We reviewed and compared the first consecutive 35 cases each of Perenze, MD Morgagni-Pierantoni Hospital - Forlì -Italy
laparoscopic and robotic colectomies performed by a single colorectal surgeon
Introduction: Robotic surgery has taken root from year to year, spreading to
at our institution from Dec 2008 to Oct 2010. Case distribution between the
several specialties. Indeed the drawback, which cut off the diffusion of robotics
Laparoscopic (L) and Robotic (R) groups were as follows: low anterior resection
among mininvasive digestive surgeons, was probably due to their major skill and
(L-3, R-9), left hemicolectomy (L-5, R-4), right hemicolectomy (L-8, R-9),
dexterity in the laparoscopic technique. Actually the robotic colectomies don’t
subtotal colectomy (L-5, R-2), sigmoid colectomy (L-4, R-6), single-port
seem to offer a clear clinical benefit compared with the laparoscopic ones. The
right hemicolectomy (L-7, R-3), transverse colectomy (L-2, R-1), Hartmann
aim of this study is to give value to the use of the Da Vinci surgical system in
(L-1) and abdominal perineal resection (R-1). Indications for surgery included
right and left colectomies.
diverticular disease, tubular adenoma and adenocarcinoma. There was no
statistical difference among age, gender and BMI between the two groups. Methods & Procedures: From March 2007 through December 2010 we performed
122 totally robotic and robot-assisted colorectal resections: 31 for benign
Results: There were no deaths associated with either group. Complications for
diseases, 91 for malignant ones. The robotic procedures included: Right
both robotic and laparoscopic resections included postoperative ileus (L-1, R-3)
Colectomy(RC) (n = 42), Abdominal-Perineal Resection (APR) (n=2), Left
and bleeding (L-1, R-1). There was a single incidence of anastomotic leak and
colectomy(LC) (n=62), Sigmoidectomy(n= 5), Anterior Resection of the
necrotizing fascitis (extraction site) in the robotic group. 8 of 35 laparoscopic cases
Rectum (ARR) (n = 8) and Resection of Left Colic Flexure (LCFR) (n = 3).
were converted to open (possible anastomotic leak, dense adhesions, possible
40 6 TH ANNUAL MIRA CONGRESS May 11-13, 2011
Results: The robotic indications were: diverticulosis (n=17), polyps (n=14) and Conclusion. Robot-assisted laparoscopic colorectal surgery requires further
cancer (n=91). Mean operative time was 325 minutes (range, 172-570). The evaluation to establish clinical and financial benefits before introduction to
conversion rate to open surgery was 7.4% (9 patients). The mean number of routine practice.
harvested lymph-nodes in malignant pathologies was 22.1 (range, 8-61). The
median length of stay was 8.3 day. The overall anastomotic leakage rate was: P025: ROBOT IN TREATING WELL-SELECTED LEFT-SIDED
3.3%. The postoperative bleedings which required the reoperation were 2 PANCREATIC CANCER- ROBOTIC ANTERIOR RAMPS Chang Moo Kang
(1.63%). There was one intraoperative complication in our series (bleeding). Yonsei University College of Medicine
Conclusions: Robotic surgery is the technologic reply to the human limitations Background: Laparoscopic distal pancreatectomy with splenectomy is regarded
in laparoscopy and its choice will contribute to the advancement of mininvasive as a safe and effective treatment for benign and borderline malignant pancreatic
surgery. It improves the performance of the surgeon and his working quality. lesions. However, its application for left-sided pancreatic ductal adenocarcinoma
Actually there aren’t indisputable proofs that the robotic system assures an (PDAC) is still debating.
obvious clinical benefit in colon resection. Further studies comparing clinical Materials & Methods: Relatively pancreas-confined tumor with intact fascia layer
and cost-effectiveness with laparoscopic surgery are required to assess the between pancreas and left adrenal gland/ kidney is thought to be potential
possible role of this technology in colorectal surgery, since that an increased indication for minimally invasive approach in treating left sided pancreatic
incidence of colorectal cancer is expected in the next decade. cancer. Four patients with pancreatic cancer were selected for robotic RAMPS.
Four robotic arms were used in supine position with the patient’s head- and
P023: RE-LEARNING CURVE IN ROBOTIC COLORECTAL SURGERY left-side elevated. Pancreatic dissection from right to left was performed
WITH A NEW DA VINCI SI HD G Spinoglio, MD, R Quarati, MD, F after division of pancreatic neck portion. Lymph nodes around common
Priora, MD, LM Lenti, PHD, F Ravazzoni, PHD, V Maglione, MD Division hepatic artery and celiac axis were dissected during this procedure. The
of Oncologic General Surgery, ASO "SS Antonio e Biagio e Cesare Arrigo", clinicopathologic characteristics and perioperative surgical outcome including
Alessandria , Italy interim oncologic outcome were analyzed.
Aim: Our robotic experience began in November 2005. The activity stopped in Result: Three patients were male and one is female with median age, 63 years
December 2007 after 216 surgical procedures. In March 2010 we obtained a old (53-72 years). Three were reported to be adenocarcinoma of the pancreas,
new Da Vinci Si HD. A re-learning curve, started with colorectal procedures, and one was invasive intraductal papillary mucin-producing carcinoma. Median
was necessary. We compared recent results of colorectal procedures to previous operation time was 390min (350-720 min) and median intraoperative bleeding
experience. was 475ml (350-700 min). Pancreatic resection margins including posterior
Methods: Proctocolectomy: 24 (1st series) - 25 (2nd series); Miles: 2 (1st series) – tangential margins were not involved by malignant cells. Median number
5 (2nd series); Left colectomy: 22 (1st series) – 14 (2nd series); Right colectomy of retrieved LNs was 8.5 (2-23). Median length of hospital stay was 7 days
25 (1st series) – 11 (2nd series). (4-11 days). All patients receive postoperative adjuvant chemotherapy within
one month after surgery. During median follow up period of 24 months, no
Results: Proctocolectomy: mean operative time (T): 444 vs 413 min. (p=0.263),
recurrence and no cancer-specific mortality were noted.
conversion rate (CR): 16% vs 12% (p=0.641); complications I-II grade: 7 vs
1 (p=0.008), complications III-IV grade: 2 vs 4 (p=0.413).No differences Conclusion: Robotic modified anterior RAMPS is technically feasible and safe
were observed in the patients’ features of two series. Left colectomy: T = for margin negative resection in well-selected left sided pancreatic cancer. The
345/321 min (p=0.436), CR 14% vs 0 (p=0.149); complications I-II grade: 2 oncologic feasibility still remains to be determined.
vs 0 (p=0.149), complications III-IV grade: 1 vs 1 (p=0.209). No differences
wereobserved in the patients’ features of two series. Right colectomy: T = P026: TRANSHIATAL VERSUS THORACOSCOPIC ROBOTIC
316/266 min (p=0.106), CR 4% vs 0 (p=0.501); complications I-II grade: 7 vs ESOPHAGEAL DISSECTION Carlos Loureiro González, Ismael Díez del
1 (p=0.209), complications III-IV grade: 0 vs 1 (p=0.501). No differences were Val, title, Inmaculada Cruz González, Saioa Leturio Fernández, Sandra Ruiz
observed in the patients’ features of two series. Carballo, José Esteban Bilbao Axpe, José Ramón Cotano Urrutikoetxea, Jaime
Jesús Méndez Martín Gastroesophageal Surgery Unit, Hospital Basurto, Bilbao
Conclusions: We observed a progressive trend to a reduced operative time and a
similar rate of conversions and complications between the two series for all the Robotic surgery may facilitate some difficult steps during esophageal surgery.
procedures. The re-learning curve was faster probably because of the previously We usually start the operation depending on the location of the primary tumor,
gained expertise and the new enabling features of Da Vinci Si HD System. i.e., laparoscopicaly for lesions at the distal third or esophagogastric union, or
thoracoscopicaly for tumors situated at the middle third.
P024: COMPARISON OF ROBOTICALLY PERFORMED AND This allows an accurate evaluation of resectability and concomitant locoregional
TRADITIONAL LAPAROSCOPIC COLORECTAL SURGERY. HC Pappis, metastases.
MD PhD FACS, N Pararas, MD PhD, D Kotsakou, MD ’Hygeia’ Hospital,
Athens, Greece The first part of the video shows progression from the stomach up to above
the carina during the transhiatal technique. After passing a Penrose drain for
Introduction: The use of the Da Vinci Robotic System is postulated to have traction around gastroesophageal union and performing the Pinotti maneuver,
better surgical results by allowing improved instrument manipulation, three- pericardium, parietal pleurae and inferior pulmonary veins are identified and
dimensional vision, enhanced precision and surgeon’s comfort. The authors’ the esophagus carefully dissected.
experience performing robot-assisted laparoscopic colorectal surgery is
reported. Then, thoracoscopic approach with the patient at the prone position is showed
for resection of a middle-third tumor. After selective intubation, the lung
Methods & Procedures: We compare standard laparoscopic procedures with robot- collapse is helped by mild CO2 insufflation up to 6mmHg. Acygos vein is
assisted colorectal surgery, including benign and malignant diseases. Between stapled (30mm-2.0 grey cartridge) through the assistant trocar. Dissection
September 2008 and December 2010, 11 robotic colorectal procedures have been progresses after identification of aorta at the upper part of the operating field,
performed (6 low anterior resections, 5 left colectomies and 1 right colectomy). and pericardium, pulmonary veins and membranous part of both bronchi and
One case has been converted to classic laparoscopic procedure and no major trachea behind. Once the whole esophagus has been freed, a pleural drain is
complication has been noted to this group of patients. We matched these cases placed and the thoracic phase concluded.
with laparoscopic ones, choosing the age/gender, and similar ASA score.
Whereas the thoracoscopic robotic approach reproduces faithfully the classical
Results: We report the comparison concerning the operative time, blood loss, thoracoscopic technique, robotic transhiatal esophagectomy represents one of the
length of stay, hospital costs and surgery related complications. Robot-assisted main contributions of robotics to esophageal surgery, improving dissection and
laparoscopic colectomy is a feasible and safe procedure. Although three- avoiding blind steps. Most patients recover without necessity of pleural drain.
dimensional vision and dexterity are facilitated, operative time is moderately
increased and the overall additional expense of robotics is of concern. Moreover,
the conclusions are not the same for all kind of procedures.

www.mirasurgery.org 41
Poster Abstracts
P027: AN INTERNATIONAL SURVEY TO EXAMINE ATTITUDES 10 cases) to 55 +/- 19 min (last 10 cases). The mean robotic time was 90 +/- 39
TOWARDS ROBOTIC SURGERY Sheraz R Markar, MRCS MA MBBChir, min. We observed almost no change in robotic procedure time throughout the
Ivana Kolic, MBBS, Alan P Karthikesalingam, MRCS MA MBBChir, Oliver J study period. The overall operative time decreased significantly from an average
Wagner, MD, Monika E Hagen, MD University College London Hospital of 250 min during the first 10 procedures to 164 min during the last 10. This
corresponds to a learning curve of 85% during our initial experience.
Introduction: The field of robotic surgery is rapidly advancing both in terms of the
surgical procedures performed and the potential applications of this technology. Conclusions: Robotic Heller myotomy offers significant advantages such as three-
The boundaries in this field are increasing being pushed, with the advent of dimensional view, easier instrument manipulations and possibility of remote
tele-surgery, remote-surgery and internal robots. With such rapidly changing site surgery. We observed some shortcomings of robotic surgery such as need
technology it becomes increasingly important to examine the views of the public for larger and additional ports, and need for undocking the machine to perform
regarding this technology. This survey study represents the first attempt to additional procedures or change the patient position. Decreases in set-up time
evaluate the opinions of the public regarding a number of issues in robotic surgery. and docking were primarily responsible for our initial learning curve.
Methods: A web-based survey study was constructed using a web-based P029: INITIAL EXPERIENCES OF ROBOT-ASSISTED POSTERIOR
programme ’Kwiksurveys’. This survey was then advertised and distributed over RETROPERITONEOSCOPIC ADRENALECTOMY (PRA); SINGLE PORT
the Internet to gain responders from a wide range of socio-economic groups and ACCESS Sang-Wook Kang, MD, Haeng Rang Ryu, MD, Jong Ju Jeong, MD,
in a number of countries. Responses were collected over a 3-month period. Woong Youn Chung, MD Department of Surgery, Yonsei University College of
Results: 153 participants took part in this survey study. The mean age of Medicine
participants was 35.8 ± 3.4 yrs. The male: female ratio was 77:74 (51% vs. Introduction : Recent advances in the technologic and surgical instrument fields
49%). 74% (113) of participants had previously heard of robotic surgery. The have resulted in the developments of robotic adrenal surgery. PRA has several
most important factor to participants when choosing their type of surgery was superior benefits comparing to the others in terms of direct and short access
post-operative complications (56%) followed by length of post-operative recovery to the target organ, no trespass and irritation of intraperitoneal space, no need
(26%), Operating surgeon’s preference (15%) and Post-operative pain (3%). The of retracting adjacent organs, and safety and ease for learning this method.
majority of participants (32%) were totally comfortable, with the current version Recently, we have experienced several cases of robot-assisted PRA using
of robotic surgery during which a surgeon in the same room controls instruments single-port access for small adrenal tumor. In this study, detailed methods and
inside the patient. 54% of participants reported they would only find it acceptable preliminary results will be introduced.
if the operating surgeon controlling the robotic instruments was in the operating
room. Furthermore only 10% of participants reported it would be acceptable for Patients & Method: From March. 2010 to July 2010, 5 patients have undergone
the operating surgeon to be in another district or country whilst controlling the robot-assisted PRA using single ports access. The patient lies as prone, jack-
robotic instruments. 59% of patients completely disagreed with the statement, ’I knife position with hip joints bending at a right angle. A 3 cm-sized transverse
would agree to be operated on by a surgeon from another country controlling the skin incision was made just below the lowest tip of the 12th rib, and the
robotic instruments by tele-surgery if it was cheaper’, with only 9% of participants Glove port® (NELIS, Kyung-gi, Korea) was applied to the skin incision and
completely agreeing with the statement. 68% of responders reported they would maintained pneumoretroperitoneum. Small vessels were ligated with Harmonic
be very uncomfortable with the idea of not seeing the operating surgeon in person Scalpel and central vein of adrenal gland was ligated with endo-clips. The
before or after surgery. When asked, ’how do you feel about intelligent robotics clinico-pathologic data of the patients were analyzed retrospectively.
that perform your surgery without direct control by a surgeon by being pre- Results: The mean age of the patients was 56.6±8.7 and 2 women and 3 men
programmed’, 68% of responders reported they would be very uncomfortable. were included. Right and left side approaches were performed in 1 and 4
45% of participants reported they would consider idea of an internal robot patients, respectively. All the cases were primary aldosteronism. The mean
operating internally with little or no external scarring. 56% of responders felt size of tumor was 1.48±0.28cm. Mean operative time was 159.4±57.6 minutes
further research in the field of robotic surgery as very important. (range 103 to 245) and mean estimated blood loss was 46.0±63.8. Average
Conclusion: This survey study has demonstrated that currently the public appear time to oral intake and postoperative hospital stay were 0.6 and 4.0 days,
to be comfortable with the current version of robotic surgery, with the operating respectively. The mean numbers of analgesics use for pain control was 1.8±0.8.
surgeon in the same room as the patient. However the idea of tele-surgery with the There was no conversion to open surgery and postoperative complications.
surgeon in another country to the patient, appears to be less well accepted. The Conclusion: Our initial experiences of robot-assisted single port retroperitoneoscopic
results of this survey study show that even with the technical advances in robotic adrenalectomy did much to assure us of its safety and feasibility. We suggest that
surgery, patients will still want to have contact with their operating surgeon. robot assisted single port retroperitoneoscopic adrenalectomy can be viewed as a
useful surgical option for the treatment of adrenal pathologies.
P028: ROBOTIC HELLER MYOTOMY: LEARNING CURVE,
ADVANTAGES, AND LIMITATIONS Eric C Nelson, MD, Mohamed R Ali, P030: ADVANTAGES OF ROBOTIC GASTRECTOMY IN
MD, William Smith, BS, Tamas J Vidovszky, MD University of California, EXTRAPERIGASTRIC LYMPHADENECTOMY COMPARED TO
Davis Medical Center, Sacramento, CA LAPAROSCOPIC GASTRECTOMY Kazutaka Obama, MD PhD, Woo Jin
Background: The surgical treatment of achalasia has well-established outcomes Hyung, MD PhD, Yanghee Woo, MD, Kyung Ho Pak, MD, Hyoung-Il Kim,
superior to medical management, and laparoscopic surgery minimizes the MD PhD, Sung Hoon Noh, MD PhD Department of Surgery, Yonsei University
morbidity of the intervention. We investigated the addition of the da Vinci College of Medicine
robotic system to the laparoscopic Heller myotomy and examined the learning Introduction: Although robotic surgery is gaining popularity, robotic gastrectomy
curve, advantages and limitation of the procedure. (RG) for gastric cancer has not widely accepted yet because advantages of RG
Material & Methods: We reviewed all (n = 29) robotic Heller myotomies still remains unclear. To evaluate the effect of robotic assistance, we focused
performed between February 2006 and July 2010. We recorded operative time, on the D2 lymphadenectomy during distal gastrectomy by robotic assistance
setup time of robotics instrumentation, conversion to laparoscopic or open in gastric cancer surgery. We investigated whether there are any advantages of
surgery and complications of the procedure. robotic surgery in lymphadenectomy over conventional laparoscopic surgery.
Results: 100% of the Heller myotomies were completed robotically, although Methods & Procedures: From May 2003 to December 2009, 316 robotic and
additional procedures during the same anesthesia were performed purely 713 laparoscopic gastrectomies were performed for gastric cancer patients
laparoscopically. We did not experience any significant complications directly in Yonsei University Severance Hospital. Among these, we performed distal
related to robotic surgery. The mean total operating time +/- standard deviation subtotal gastrectomy with D2 lymphadenectomy for 97 patients by robotic
was 219 +/- 66 min. When the six procedures which involved additional hernia and for 258 patients by laparoscopic. We retrospectively compared patients’
repairs or pyloromyotomies are excluded, the mean operating time was 207 characteristics, retrieved number of lymph nodes (LN) at each LN station,
+/- 65. The mean setup time for robotics (from incision until robot was in operative outcomes and postoperative complications between robotic distal
place, including draping the robot) was 75 +/- 34 min. However, the setup time gastrectomy (RDG) group and laparoscopic distal gastrectomy (LDG) group
significantly improved as we gained more experience: from 102 +/- 36 min (first using prospectively maintained database.

42 6 TH ANNUAL MIRA CONGRESS May 11-13, 2011


Results: With regard to the patients’ characteristics, there was no significant gastrojejunostomy performed, once the jejunum has been sectioned about 40cm
difference of gender, BMI, histology, tumor location, tumor size and depth distal to the Treitz angle. Entero-enterostomy can be performed mechanically
of invasion, between the two groups. However, RDG group was significantly or through the 4 to 5cm incision used to extract the specimen. Totally robotic
younger than LDG group (53.1±13.0 and 58.5±12.0, respectively) and nodal subtotal gastrectomy is feasible and safe. Its main advantages seem to be a more
involvement differed significantly between the two groups; positivity of LN accurate lymphadenectomy and easier hand-sewn anastomoses. The future will say
metastasis of RDG group was higher than LDG group (32.0% amd 17.1%, about its applicability in large series.
respectively). Regarding retrieved number of suprapancreatic LNs (#7, 8, 9,
11p, 12a), significantly more LNs were dissected in RDG (15.7±7.4) than in P033: FROM LAPAROSCOPIC TO ROBOTIC GASTROESOPHAGEAL
LDG (13.6±7.3) (p=0.016). When we analyzed the patients who received SURGERY Ismael Díez del Val, Carlos Loureiro González, Sandra Ruiz
D2+#14v LN dissection (77 patients in RDG, 171 in LDG), retrieved number Carballo, Saioa Leturio Fernández, Inmaculada Cruz González, José
of extraperigastric LNs (suprapancreatic LNs + #14v) was also significantly Esteban Bilbao Axpe, Jaime Jesús Méndez Martín, Ángel Gómez Palacios
more in RDG (17.7±8.0) compared to LDG (15.6±7.7) (p=0.045). Among Gastroesophageal Surgery Unit, Hospital de Basurto, Bilbao
extraperigastric LN stations, retrieved numbers of LNs in RDG were significantly Objective of the Study: To evaluate the feasibility and safety of robotic
more in station No.9 and No.11p (4.6±3.4 and 2.5±2.8) than those in LDG gastroesophageal surgery in a surgical unit with experience in the same
(3.6±3.3 and 1.8±2.4) (p=0.018 and 0.014, respectively). Retrieved number of procedures by open or laparoscopic approach.
LNs in station No.12a also differed between RDG (2.0±2.3) and LDG (1.5±2.2),
although this difference was marginal (p=0.067). Regarding operative outcomes, Methods & Procedures. From September 2009 to November 2010, 32 patients
mean operative time in RDG (217min) was 46min longer than that in LDG (19 men and 13 women) with different gastroesophageal diseases underwent
(171min) (p<0.001), whereas mean blood loss was significantly less in RDG laparoscopic surgery with a Da Vinci robotic system at our Institution. Mean
(56ml) compared to LDG (131ml) (p<0.001). Occurrence rate of postoperative age was 60.5 years. First of all, we performed 6 anti-reflux surgery cases to
complications did not differ between the two groups. advance in the learning curve. Progressively, all kind of pathologies currently
treated at our Unit were submitted to robotic surgery: 7 paraesophageal hernia
Conclusions: These data suggest that robotic assiatnce may help surgeons perform repairs, 1 redo, 3 cases of achalasia, 9 esophageal neoplasms (6 transhiatal and 3
more complete D2 lymphadenectomy than laparoscopic surgery during by thoracoscopy), 2 gastric cancers, 1 middle-third leiomyoma, 1 morbid obesity
gastrectomy for gastric cancer with same safety. Further studies are required and 2 gastric stromal tumors (GIST).
to clarify whether this advantage of robotic surgery affects long term outcomes
(local recurrence and survival) of gastric cancer patients. Results: Mean hospital stay was 14.1 days for patients diagnosed of esophageal
carcinoma and 4.7 for the rest of the series. All the procedures but three were
P031: ROBOTIC REDO FOR FAILED LAPAROSCOPIC NISSEN completed endoscopically. Two elective conversions to open surgery were due
FUNDOPLICATION Ismael Díez del Val, Carlos Loureiro González, Sandra to difficult posterior gastric dissection at the end of a transhiatal esophagectomy
Ruiz Carballo, Saioa Leturio Fernández, Inmaculada Cruz González, José in one case and to the impossibility to reduce an intrathoracic gastric volvulus in
Esteban Bilbao Axpe, Jaime Jesús Méndez Martín, Ángel Gómez Palacios another one; the third case corresponds to an unresectable squamous carcinoma
Gastroesophageal Surgery Unit, Hospital de Basurto, Bilbao, Spain whose preoperative pathologic diagnosis was leiomyoma. We had two major
complications requiring reoperation: one leak in the stapled line of the gastric
We present a case of failed laparoscopic Nissen in a young woman operated on tube after a transhiatal esophagectomy and one case of intrathoracic gastric
18 months before for gastroesophageal reflux disease (GERD). The operation migration after dissection of the greater curvature and lower esophagus in a case
consisted on acalibratedcrura closure anddivision of short gastric vessels, with of esophageal carcinoma that was stopped due to carcinomatosis implants on the
fundoplication not sutured to the esophagus. anterior aspect of the pancreas. One cervical fistula was treated conservatively.
She presented progressive dysphagia. The esophagogram showed a slipped All the complications were observed in patients suffering from esophageal
Nissen with the fundoplication lying down on the gastric body. carcinoma. Mortality was nil.
The robotic technique starts by freeing adhesions from previous surgery. Once Conclusions: Robotic gastroesophageal surgery is feasible and safe. Its main
the crura and the fundoplication are identified, we pass a Penrose drain around contribution seems to be mediastinal dissection, either for giant hernias,
distal esophagus for traction. Greater curvature and His angle are exposed myotomy or transhiatal esophagectomy. The observed complications were not
and fundoplication completely taken down. Finally, after guaranteeing the directly related to the robotics itself, but rather to the complexity of the patient
intrabdominal location of the distal part of the esophagus, a new short floppy or the pathology. Experience in open and laparoscopic surgery may contribute to
Nissen is performed, adequately secured to the esophagus. reduce the learning curve.
Robotic surgery enhances image stability, allows fine dissection and P034: ROBOT-ASSISTED TRANSHIATAL ESOPHAGECTOMY Carlos
identification of structures. We consider that this approach may become the gold Loureiro González, Ismael Díez del Val, José Esteban Bilbao Axpe, José Ramón
standard for reoperations in this anatomic region. Cotano Urrutikoetxea, Jaime Jesús Méndez Martín Gastroesophageal Surgery
unit, Hospital de Basurto, Bilbao
P032: TOTALLY ROBOTIC SUBTOTAL GASTRECTOMY FOR CANCER
Carlos Loureiro González, Ismael Díez del Val, Inmaculada Cruz González, Introduction. Minimally invasive surgery is a quite new approach for the
Saioa Leturio Fernández, Sandra Ruiz Carballo, José Esteban Bilbao Axpe, treatment of esophageal cancer. Thoracoscopic approach in the prone position
Jaime Jesús Méndez Martín Gastroesophageal Surgery Unit, Hospital de could be considered the gold standard of treatment because it allows a precise
Basurto, Bilbao dissection of the thoracic esophagus avoiding the morbidity of the thoracotomy.
Nevertheless, in lower-third esophageal carcinoma, especially adenocarcinoma,
Robot-assisted gastrectomy has been demonstrated feasible and safe in a few
the possibility of unexpected unresectable disease or peritoneal metastases
published reports. After several years’ experience with open and laparoscopic
makes it advisable to carry out an initial laparoscopic approach. Without any
gastrectomy, we have started performing totally robotic Roux-en Y gastrectomy,
change in the position of the patient, transhiatal esophagectomy is an attractive
that reproduces quite faithfully the previous technique, except that clips and
but complex option that may be facilitated by robotic surgery. The aim of this
staplers are introduced by the assistant. The patient is placed in the reverse
presentation is to evaluate the contribution of robotics to the surgical treatment
Trendelenburg position, with the first assistant between the legs. The surgeon’s
of lower-third esophageal carcinoma.
left hand’s instrument passes through an 8mm-robotic trocar telescoped into
a 12mm’s one, to fire staplers when needed. Another 12mm trocar is placed Methods & Procedures. From January to November 2010, 5 patients between 51
on the left midclavicular line for assistant and, at the end of the operation, to and 70 years old, all males, underwent a robotic transhiatal esophagectomy
remove surgical specimen. After freeing the great omentum, right gastroepiploic for cancer at our Institution, 6 to 8 weeks after completing neoadjuvant
vessels are divided at their origin, including group 6 nodes, and the duodenum radiochemotherapy. Three 8mm-robotic trocars are used, one of them for liver
transected. Then, right gastric artery is clipped and lymphadenectomy performed and pericardial retraction. After hiatal dissection, a Penrose drain is passed
along the common hepatic artery to the celiac axis and, after ligating the left for traction, followed by progression up to above the carina. At the level of the
gastric vessels, continued up to the right diaphragmatic crus. The stomach is inferior pulmonary veins, the 30o camera is changed to 0o, to improve anterior
divided with several blue-cartridge linear staplers, and a tension-free hand-sewn dissection. Direct branches from the aorta are sealed with harmonic o bipolar
www.mirasurgery.org 43
Poster Abstracts
cautery. Eventual openings of the pleurae are treated by decreasing abdominal Results: Twenty eight papers were identified including multiple publications
pressure to 10mm Hg. Because no major contamination of the pleural space of the same series. There were no randomized clinical trials. Most of the
occurs, no thoracic drains have been placed. Although we have performed trials were retrospective studies, case series and case reports, that described
Kocher maneuver, gastric tube stapling or pyloroplasty by robotic surgery, the author’s experience in robotic thyroidectomy. One small clinical trial
we prefer doing it by conventional laparoscopy, after undocking the Da Vinci compared robot assisted endoscopic with open thyroidectomy and one
system. The surgical specimen is removed through a left lateral cervicotomy, small retrospective study compared conventional endoscopic with robotic
and a hand-sewn anastomosis carried out. thyroidectomy. Patient selection criteria varied among different studies. Thus,
robot assisted thyroidectomy was applied for predominant benign nodules <
Results. Four procedures were completed laparoscopicaly. One elective
4 cm or < 5 cm and for malignant or potentially malignant nodules < 2 or <
conversion was needed due to difficult posterior gastric dissection, once
4 cm at its largest diameter. The thyroid gland was approached laterally using
the esophagus had been completely freed. We had a leak at the staple line
the gasless trans-axillary approach, unilateral axillary- breast approach, the
of the gastric tube requiring reoperation and a cervical fistula managed in a
bilateral axillary-breast approach. Direct transoral approach to the thyroid
conservative way, but none of these events were directly related to the robotic
gland was applied in two cadavers. Robot assisted operations performed
approach. The mean number of lymph nodes harvested was 12 per patient
included total thyroidectomy, lobectomy, total thyroidectomy with modified
(range: 6 to 19). The mean hospital stay was 17,4 days (10-32). There was no
lateral neck dissection, total thyroidectomy with central node dissection,
mortality in the series.
subtotal thyroidectomy with central node dissection. Indications included well
Conclusions. During transhiatal esophagectomy, the surgeon has to work in a differentiated thyroid carcinoma with lateral node metastasis, multinodular
narrow deep operating field, where robotic surgery has several advantages: goiter with predominant nodule, indeterminate nodules. Operative time
image stability, instruments length and degrees of freedom, precision of ranged from 67 to 279 min. Approximately 25% of the time was spent
movements, improved dexterity. Although this technique is complex and docking and setting the robot machine. Complications included transient
complications frequent, we consider that it represents one of the main recurrent laryngeal nerve palsy, transient hypocalcaemia, permanent ipsilateral
applications of robotic surgery. recurrent laryngeal nerve palsy, permanent hypoparathyroidism, transient
hoarseness, Horner’s syndrome, postoperative muscle flap hemorrhage, tracheal
P035: ROBOT-ASSISTED THYROIDECTOMY BY TRANSAXILLARY injury, wound seroma, wound erythema, brachial plexus neuropraxia due to
APPROACH Nicolae Constantea, Profesor PhD MD, Dan Axente, MD 5th traction injury. A drawback of robotic thyroidectomy observed in a number
Surgical Clinic, Cluj-Napoca County Hospital, Romania of studies was a remnant little thyroid tissue (>1-2 gr) at Berry’s ligament or
Background: Over the past 2 decades many endoscopic thyroidectomy the upper pole of the contralateral side due to an insufficient surgical angle.
procedures have been developed trying to minimize visible scarring and to Concerning comparison with open or conventional endoscopic thyroidectomy,
reduce postoperative pain. Recently robotic technology has been also applied early operative outcomes seem satisfactory in terms of hospital stay, pain,
to thyroid surgery using a gasless transaxillary approach. Our objective was to complications and degree of complete resection.
evaluate the technical feasibility, intraoperative safety and efficacy of this new Conclusion: Limited available data suggest that robot assisted thyroidectomy is
robotic procedure. feasible and safe. However, drawbacks exist, i.e. the extent of trauma seems
Methods: We used the da Vinci SI Surgical Robotic System and we performed 9 larger. Large multicenter studies are needed to evaluate patient selection
total unilateral lobectomy via transaxillary approach without gas insufflation. criteria, postoperative morbidity due to laryngeal nerve injury and to
All 9 patients were diagnosed with unilateral thyroid nodules. For each patient, hypoparathyroidism, long term oncologic and cosmetic results.
we analyzed the clinical characteristics, tumor size, pathologic type, operative
time, amount of drainage, duration of hospital stay, postoperative complications, P037: FEASIBILITY AND SAFETY OF ROBOT ASSISTED-
postoperative neck and anterior chest pain, and cosmetic satisfaction. ADRENALECTOMY -SYSTEMATIC REVIEW Eugenia Yiannakopoulou, MD
Msc PhD, Nikolaos Nikiteas, MD PhD, Christos Tsigris, MD PhD Faculty of
Results All operations were performed successfully without any need for Health and Caring Professions Technological Educational Institute of Athens,
conventional open conversion. The mean overall operation time was 170 min. 2nd Department of Propedeutic Surgery School of Medinice NKUA, 1st
respectively 90 min. console time. The mean tumor size was 3.8 cm. There was Department of Surgery School of Medicine NKUA
one temporal brachial plexus neuropraxia and one wound seroma. There were
no malignant thyroid lesions. Background: The first robotic adrenalectomy in humans was reported in 2001
by Horgan and Vanuno. The robotic approach is an interesting option for
Conclusions Robotic thyroidectomy by gasless transaxillary method is feasible, overcoming the limitations of laparoscopic adrenalectomy as it offers three
safe, and provided good outcomes. Robotic technology overcame some technical dimensional view and faster learning curve. However, evidence on the role of
limitations associated with conventional endoscopy. robotic adremalectomy is limited. This study is a systematic review that aims to
summarize data on the feasibility and safety of robot-assisted adrenalectomy.
P036: FEASIBILITY AND SAFETY OF ROBOT ASSISTED-ENDOSCOPIC
THYROIDECTOMY-SYSTEMATIC REVIEW Eugenia Yiannakopoulou, MD Methods: Pubmed, Scopus, Google Scholar were searched with the appropriate
Msc PhD, Nikolaos Nikiteas, MD PhD, Christos Tsigris, MD PhD Faculty of search terms up to and including December 2010. Clinical trials randomized or
Health and Caring Professions Technological Educational Institute of Athens, not, retrospective studies, case series, case reports, cadaver and experimental
2nd Department of Propedeutic Surgery School of Medinice NKUA, 1st studies were all included. Papers published only in abstract form or presented
Department of Surgery School of Medicine NKUA in congresses were excluded. Extracted data included type of study, number
of patients, indication of adrenalectomy, surgical technique applied, operative
Background: Robotic thyroidectomy is a new approach to thyroid surgery, that time, final pathology, conversion rate, complications.
offers the benefit of eliminating the anterior neck incision utilized in traditional
approaches. Additional advantages include three dimensional working field, Results: Thirty six trials were identified and they were obtained in full text.
a magnified view, tremor filtering system, multiarticulated instruments. Seven publications were previous double or multiple publications of smaller
However, no level I evidence exists to strongly support the robotic approach to series and therefore were excluded. Most of the trials were retrospective studies,
thyroid surgery. This study is a systematic review that aims to summarize data case series and case reports, that described the author’s experience in robot
on the feasibility and safety of robotic thyroidectomy. assisted adrenalectomy. One randomized clinical trial (RCT) was identified, that
compared robot-assisted with laparoscopic adrenalectomy. Two experimental
Methods: Pubmed, Scopus, Google Scholar were searched with the appropriate studies were also included. According to available data, two hundred eighty
search terms up to and including December 2010. Clinical trials randomized or two patients have been submitted to robot assisted adrenalectomy. Operations
not, retrospective studies, case series, case reports, cadaver and experimental performed included left sided robot-assisted transperitoneal adrenalectomy,
studies were all included. Papers published only in abstract form or presented right sided robot-assisted transperitoneal adrenalectomy, bilateral robot-assisted
in congresses were excluded. Extracted data included type of study, number adrenalectomy, robotic posterior retroperitoneal adrenalectomy, robotic partial
of patients, indication of thyroidectomy, surgical technique applied, operative adrenalectomy. Indications included glucocorticoid secreting adenoma, adrenal
time, number of lymph nodes extracted in case of dissection, final pathology, hyperplasia (one bilateral), incidentaloma, cortical adenomas, multilocular
conversion rate, complications.
44 6 TH ANNUAL MIRA CONGRESS May 11-13, 2011
haemorrhagic cysts, pheochromocytoma, aldosteronoma, myelolipoma, thyroid surgery. The aim of this study is to evaluate the feasibility and efficacy of
non functioning adenomas, ganglioneuroma, lymphangioma, adrenocortical intraoperative neuromonitoring (IONM) of EBSLN in robotic thyroid surgery.
carcinoma, metastatic lesions (colorectal cancer, adrenal carcinoma). Robotic Patients & Methods: We analyzed 42 patients who underwent IONM of the EBSLN
resection of pheochromocytoma in the second trimester of pregnancy has also (group 1) and 26 patients who did not undergo IONM of the EBSLN (group
been reported. A limited number of complications were reported. Intra-operative 2) during robotic thyroidectomy. Voice assessment was prospectively obtained
complications included intraoperative bleeding in three patients, due to injury to by the Voice Handicap Index-10 (VHI-10) questionnaire before, 2-4 weeks,
the spleen in one patient with 6 cm left pheochromocytoma, from right renal vein and 3 months after surgery. The VHI-10 is a valid and reliable tool to assess
injury in an obese patient with a 2 cm right incidentalloma, and from the right the severity of voice handicap quantitatively. The Nerve Integrity Monitor
adrenal vein in an obese patient with Cushing’s adenoma, intraoperative capsular (NIM Respone 2.0 System, Medtronic Xomed, Jacksonville, FL) was used for
tear and in two patients with large phaeochromocytomas (6 and 7,5 cm). Post- the EBSLN monitoring and EBSLN is stimulated by direct contact with the
operative complications included one death in a patient with pheochromocytoma modified monopolar probe. The stimulation level was set at 1mA as a starting
due to fatal arrhythmia following myocardial infarct, diarrhea due to Clostridium point and the event threshold of 100uV; if no signal was elicited, the stimulation
difficile, pneumonia, urinary tract infection, wound trauma. The rate of was increased to 2mA. The identification of EBSLNs is confirmed by an audible
conversion from robotic assisted to laparoscopic or open adrenalectomy ranges acoustic signal or contraction of the cricothyroid muscle.
from 0 to 5%. However, in the RCT, that included ten patients in each group,
the authors reported 40% conversion rate to laparoscopic adrenalectomy due to Results: The recurrent laryngeal nerve was identified with visualized and IONM in
malpositioning of trocars. all patients during thyroid surgery. When the patients in group 1 were compared
with patients in group 2 exhibited a significant difference in patients’ self
Conclusion: Limited available data suggest that robot assisted adrenalectomy is assessment of voice severity using the VHI-10 before, 2-4 weeks, and 3 months
feasible and safe. However, the advantages of robotic adrenalectomy for the after surgery (0.47, 3.93, 0.74 [group 1] vs. 0.46, 5.85, 2.31 [group 2], p =
patients have not been defined yet, although it seems that robotic adrenalectomy 0.0399, repeated measure ANOVA). In group 1, a total of 83 EBSLNs were at risk,
confers advantages for obese patients and for patients with large tumors. 51 EBSLNs (61.4%) were visualized and identified by IONM 24 EBSLNs (28.9%)
Randomized clinical trials are needed to compare robotic assisted with were identified by IONM only, and 8 EBSLNs (9.6%) was not identified.
conventional adrenalectomy and to evaluate the safety of robotic adrenalectomy.
Conclusion: From this study it is suggested that IONM of the EBSLN during
P038: A PROSPECTIVE COMPARISON OF THE VOICE QUALITY AFTER robotic thyroidectomy is a feasible and helpful to preserve voice quality. Future
ROBOTIC VERSUS CONVENTIONAL OPEN THYROIDECTOMY FOR studies will be required to ascertain the efficacy of IONM of the EBSLN using
THE PAPILLARY THYROID CANCER 2Jong Ho Yoon, 3Chi Young Lim, objective assessment.
1Kyu Hyung Kim, 1Jae Hyun Park, 1Sohee Lee, 1Haeng Rang Ryu, 1Sang-Wook
Kang, 1Jong Ju Jeong, 1Kee-Hyun Nam, 1Woong Youn Chung, 1Cheong Soo P040: ROBOTIC SURGERY FOR MORBID OBESITY: ROUX-EN-Y
Park 1Yonsei University College of Medicine,2Asan Medical Center, University GASTRIC BYPASS, GASTRIC BANDING, SLEEVE GASTRECTOMY
of Ulsan College of Medicine, 3National Health Insurance Corporation Ilsan Christina Delimpalta, Archontis Zampogiannis National And Capodistrean
Hospital University Of Athens, Medical School And 1st Surgical Clinic, Laikon Hospital,
Athens, Greece
Purpose: The aim of this study was to evaluate and compare the voice quality after the
robotic and conventional open thyroidectomy for papillary thyroid cancer (PTC). Introduction: In the last decade laparoscopic surgery has become treatment of choice
for a large number of patients with morbid obesity, with good outcomes and few
Patients & Methods: Among total of 72 patients with PTC, 35 and 37 patients complications. The advent and gradual implementation of robotic surgery has
underwent a robotic thyroidectomy using a gasless, transaxillary approach (the initiated studies looking into its possible usage in bariatric surgery with an aim
robotic group; RG) and a conventional open thyroidectomy (the conventional open of even better results and outcomes, as it overcomes many of the laparoscopic
group; OG), respectively. To evaluate the voice quality, we performed objective techniques’ limitations: it offers a three-dimensional view, better ergonomics when
computerized acoustic voice analysis (CAVA) and subjective scaled evaluation dealing with the thick abdominal walls of the morbidly obese and the ability to
of the voice (SSEV) including Korean voice handicap index (KVHI) and Korean perform more manipulations and complex, precise suturing in a small work space.
voice-related quality of life (KVRQOL). The CAVA was done preoperatively and
3 months after thyroidectomy. The SSEV was done preoperatively, and 1 week Methods & Procedures: Review of the current literature concerning use of robotic
and 3 months after thyroidectomy. Two groups were compared in terms of pre- technology for gastric bypass, gastric banding and sleeve gastrectomy in
and postoperative objective CAVA and SSEV. The CAVA was analyzed with 5 morbidly obese patients and its possible benefits versus standard laparoscopy.
parameters including the mean fundamental frequency, jitter, shimmer, noise to Results: The most common robotically performed bariatric procedure is gastric
harmonic ratio and maximal phonation time. bypass. Studies show it is equally efficient with laparoscopic bypass where excess
Results: The mean age of RG was younger than that of the OG, but there was body weight loss is concerned. Operative times seem to be longer, although the
no significant difference in gender, tumor size, T stage, N stage, and TNM difference drops as the OR team gets acquainted with the equipment. When robot
stage. Preoperative CAVA, KVHI and KVRQOL showed no difference between docking time is excluded, the actual operation time is shorter and there is even
the two groups. In the objective CAVA, each parameter was not changed one large study showing shorter operating times for the overall robotic procedure.
by thyroidectomy in both groups. Also, the alteration of parameters was Complication rates are similar to those of traditional laparoscopy (10-24%), but
not different between the RG and OG.. In the SSEV, KVHI and KVRQOL most studies show a very significant decrease in anastomotic leaks, likely due to
showed lower voice quality postoperatively than preoperatively. But, there improvement that comes from lack of abdominal wall torque, and the advantages
was no statistically significant difference in postoperative scores of KVHI and the 3-D view of the field affords when performing the gastrojejunal anastomosis.
KVRQOL between the two groups. In most series conversion rate from robotic to laparoscopic is < 5%. The reported
mortality rate ranges between 0 and 1.8% with a morbidity of 1-3.1%. The robotic
Conclusions: Taking together, there was no major alteration in objective technique seems to have a lower learning curve of 30-50 cases, in contrast with
phonatory parameters of the patients after thyroidectomy, despite that the the 70-100 of the laparoscopic bypass. The method’s cost-effectiveness has not
patients felt the quality of their voice was low. Also, the voice quality after been specifically addressed. Elevated costs for the robotic bypass are considered
thyroidectomy was not different between the two groups. a given, although many claim that cost differences are largely caused by the
increased OR time rather than increased instrument costs. Gastric banding and
P039: INTRAOPERATIVE NEUROMONITORING OF THE EXTERNAL
sleeve gastrectomy have been successfully performed robotically, but the relative
BRANCH OF THE SUPERIOR LARYNGEAL NERVE DURING ROBOTIC
simplicity of the operations along with significantly elevated costs and increased
THYROID SURGERY Su-jin Kim, Kyu Eun Lee, Mi Ra Kwon, Kwan Yoon,
operative times do not show a clear benefit versus the traditional laparoscopic
Hyuk Jae Choi, Jun Young Choi, Yeo-Kyu Youn Haeundae Paik Hospital, Seoul
approach. However, the biggest series show very low morbidity and no mortality
National University Hospital, Korea
in the robotic groups, and, especially for banding, a greater ease when working in
Background: Changes of the voice caused by injury of the external branch of the small areas and patients with BMI > 60, as instruments are thicker and provide
superior laryngeal nerve (EBSLN) during thyroid surgery diminished quality of relief to the surgeon.
life. Therefore, identification and preservation of the EBSLN is important during
www.mirasurgery.org 45
Poster Abstracts
Conclusions: Initial studies show that robotically-assisted bariatric surgery is P043: ROBOTIC APPROACH FOR HYDATID HEPATIC CYSTS Sorin Paun,
feasible, with the same if fewer complications as laparoscopic techniques and PhD, Roxana Ganescu, MD, I Negoi, MD, Mihaela Burtea, MD, B Gaspar, PhD,
important benefits such as very low rates of anastomotic leaks. Concerns such as M Beuran, PhD Emergency Hospital - Bucharest, Romania
higher costs and longer operating times seem to be both connected to the degree Robotic surgery is a controversial approach for a liver hydatidosis disease, as well
of the OR team’s experience, and will probably be addressed more extensively as other minimally invasive techniques.
as more and more centers use robots for their patients.
Two patients with hydatid hepatic cysts were operated by robotic approach in
P041: ENDOSCOPIC AND ROBOTIC THYROID SURGERY WITH LATERAL Bucharest Emergency Hospital in the last 8 months - we are highlighting the
NECK DISSECTION FOR PAPILLARY THYROID CARCINOMA USING A benefits of minimally invasive surgery for this type of pathology.
BILATERAL AXILLO-BREAST APPROACH June Young Choi, MD, Kyu Eun A retrospective analysis for two cases is presented: the first one, a 27 years old
Lee, MD PhD, Yeo-Kyu Youn, MD PhD Seoul National University Hospital female was diagnosed by the CT scan with 3 very large hydatid cysts located
Background & Objectives: Conventional open thyroid surgery with lateral neck in II-III, VI-VII and VII-VIII liver segments and a robotic transperitoneal
dissection for papillary thyroid carcinoma (PTC) requires a long incision and approach was performed after 2 weeks of Albendazol treatment and all 3
thus leaves a cosmetically unfavorable scar. We developed the bilateral axillo- cysts were inactivated, evacuated and Lagrot pericystectomies with cavities
breast approach (BABA) for endoscopic and robotic thyroidectomy and applied drainages were performed. Total operating time riched almost 5 hours
to lateral neck dissection for PTC patients. The aim of this study was to evaluate and postoperative hospital stay noticed 11 days but with no inconvenient
completeness and feasibility of each procedure. immediate post-op symptomatology. The second case, a 52 years old female,
with one segment VIII hydatid hepatic cyst was operated by robotic approach
Materials & Methods: From June 2004 to May 2009, 27 endoscopic cases, and
– remnant cavity developed after 2 moths a billiary leakage abcess (due to too
from February 2008 and September 2010, 34 robotic cases with PTC and
soon removal of the drainage tubes) and laparoscopic reintervention for cavity
suspected lateral lymph node metastases were selected. After performing
drainage was necessary.
thyroidectomy and central compartment dissection, ipsilateral lateral neck
dissection was performed using BABA. We are able to say that the treatment of hydatid hepatic cyst is easier to be
performed by robotic surgery if the cyst localization is difficult to be reached by
Results: Endoscopic and robotic thyroidectomy and lateral neck dissection were
open or even laparoscopic procedure. Total operating time can be increased but
performed successfully in most patients, but 2 robot cases were converted to
we think that it is a matter of personal experience of the surgeon. Postoperative
open due to bleeding. Mean tumor size were 0.85±0.44cm in endoscopic cases
complications for robotic technique are similar to the other approaches.
and 0.84cm±0.43cm in robotic cases (p=0.264). Mean operative time were
181.3±45.4min in endoscopic cases and 177.0±33.7min in robotic cases (p=0.249). P044: ROBOTIC ADRENALECTOMY FOR BENIGN AND MALIGNANT
The yields of lymph node were 3.26±1.95 in central and 4.52±3.65 in lateral PATHOLOGIES Archontis Zampogiannis, Christina Delimpalta National And
compartment in endoscopic cases, 6.59±4.55 and 5.82±4.19 in robotic cases Capodistrean University Of Athens, Medical School And 1st Surgical Clinic,
(p=0.075, p=0.289). Nine patients (33.3%) had central node metastases and 5 Laikon Hospital, Athens, Greece
patients (18.5%) had lateral node metastases in endoscopic cases, 12 patients (35.3%)
and 6 patients (17.6%) in robotic cases, respectively. (p=0.517, p=0.808) During Introduction: Laparoscopic adrenalectomy is the standard method of removing
and after the operations, no significant blood loss or postoperative complications benign adrenal tumors and some malignant ones. Although significantly more
occurred and no evidences of residual disease were found at follow-up. beneficial for the patient than the open approach, it is a complex operation,
with the two-dimensional view and difficulty in instrument handling and
Conclusion: Endoscopic and robotic thyroid surgery with lateral neck dissection using hand coordination rendering it very demanding for every surgeon. After its
a BABA has results of similar operative outcomes including good cosmetic outcome development, robotic technology has been used to perform adrenalectomies
and has low postoperative complications. Therefore it is feasible and safe to apply for mostly any underlying pathology, with the hopes of overcoming some of the
these procedures to the PTC patients with suspected lateral lymph node metastases. aforementioned technical obstacles.
P042: ROBOTIC APPROACH FOR ABDOMINAL HERNIAS - A Methods & Procedures: We reviewed published literature concerning robotic
ROMANIAN EXPERIENCE Sorin Paun, PhD, Roxana Ganescu, MD, M adrenalectomy.
Beuran, PhD, C Turculet, PhD, F Iordache, PhD, I Negoi, MD, D Surdeanu, Results: In most studies the robotic procedures were undertaken using
MD Emergency Hospital - Bucharest, Romania the da Vinci Robotic System, with 5 entry ports for the system and the
Minimally invasive surgery tries to become the first choice for abdominal walls service trocars. Compared with the lateral transperitoneal laparoscopic
defects approach. We strongly believe that the robotic technique provides adrenalectomy, the robotic procedure offers better, three-dimensional
several advantages over the classic laparoscopy. visualization of the adrenal glands and their vasculature (facilitating especially
vain dissection from the vena cava), bigger freedom to move surgical
We are presenting our robotic experience concerning this type of pathology: for
instruments and elimination of the surgeon’s physical exertion. As a result,
the last two years and a half, we did perform 27 robotic procedures with classic
blood loss is cut by about 50%. On the other hand, operative times are still
3-arms DaVinci system for abdominal hernias: 14 inguinal hernias (4 recurrent),
significantly longer, with the possible exception of cases where patients have
6 postoperative ventral hernias, 4 umbilical hernias and 3 epigastric hernias.
higher BMI and/or large tumors, when the laparoscopic procedure seems
We had patient from 23 to 79 years old with hernias from 2 to 10 cm and an
to be more time-consuming. Importantly, it has been noted that OR time
anterior transperitoneal abdominal robotic approach was performed in all cases.
in itself improves after a learning curve of about 20 cases, as the surgeon’s
For inguinal hernia the procedure was performed using either 0º or 30º camera
experience augments. The robotic approach carries a higher morbidity (7-20%
and for postoperative, umbilical or epigastric hernia the choice was for 30º up
vs 0%) and a conversion rate to laparoscopic or, unusually, to open procedure
camera. Dissection time was between 55 and 195 min with an OR time from
(5-7%, 40% in one study). Post-operative complications are rare and the
100 to 351 min (including robot preparation) with a minimum of blood lose (0-
duration of hospital stay is equal to that of the laparoscopic procedure. Cost,
30ml) and no complications were recorded. Postoperative hospital stay was from
however, remains an important drawback, amounting to 1,5-3 times that of
1 to 5 days. We did also noticed two patients with bilateral inguinal hernias (one
laparoscopic or conventional open adrenalectomy. Recently, there have been
of them with a recurrent inguinal hernia on one side) operated by TAPP fully
case reports of robots used in minimally invasive partial adrenalectomy in
robotic technique, one-step procedures (polypropylene mesh repairs on both
patients with hereditary conditions affecting both glands, as well as in gland
sides for both patients). Total operating time was increased for these two cases
removal because of malignancy. As far as the first scenario is concerned, due
but hospitalization time was very low.
to its special technical aspects, robotic adrenalectomy is probably going to
Regarding our experience we can say that the robotic instruments offered a very be extremely useful in similar cases, where sparing the gland is of pivotal
good technicality for the console surgeon in every case, despite the position of the importance for the patient’s well-being.
hernia or its dimensions. Robotic repair is able to achieve the same results as the
Conclusion: Robotic adrenalectomy is feasible and has comparable results with
open or laparoscopic surgical procedure while reducing postoperative hospital stay
the standard laparoscopic procedure. Preliminary results indicate subjective
and no complications.
advantages -mainly for the surgeon- but have failed to demonstrate superior
46 6 TH ANNUAL MIRA CONGRESS May 11-13, 2011
performance after comparison with the laparoscopic approach. Therefore its P047: COMPARISON OF PERIOPERATIVE OUTCOMES BETWEEN
implementation is mostly on a trial basis, but it is probable that it will become HAND-ASSISTED LAPAROSCOPIC WHIPPLE’S OPERATION AND
more widespread as costs dwindle and surgeons gain more experience with ROBOT-ASSISTED LAPAROSCOPIC WHIPPLE’S OPERATION Eric
robotic equipment. C.H. Lai, MBChB MRCSEd FRACS, Chung Ngai Tang, MBBS FRCS, George
P.C. Yang, MBBS MRCSEd FRACS, Oliver C.Y. Chan, MBChB MRCSEd
P045: GIST DUODENAL RESECTION AND RECONSTRUCTION IS A FRCS, Michael K.W. Li, MBBS FRCS Department of Surgery, Pamela Youde
FEASIBLE ROBOTIC PROCEDURE T . P Singh, MD, Eyad Wohaibi, MD, Nethersole Eastern Hospital, Chai Wan, Hong Kong SAR, China
James Massullo, MD Department of Surgery Albany Medical Center
Introduction: To compare the short term outcome between hand-assisted
Duodenal Gastrointestinal Stromal Tumor (GIST) tumors are rarely seen. laparoscopic Whipple’s operation and robot-assisted laparoscopic Whipple’s
Most surgical treatments for this finding require open surgical intervention. operation.
We describe a case of a Duodenal GIST tumor found secondary to GI bleeding.
Methods & Procedures: A non-randomized comparative study was conducted on
Work up prior to surgery showed a localized lesion in the 2nd/3rd portion of
18 consecutive patients, who underwent hand-assisted laparoscopic Whipple’s
the duodenum without metastatic extension. This tumor was safely resected
operation (n=10) and robot-assisted laparoscopic Whipple’s operation (n=8)
and duodenal reconstruction via duodeno-jejunostomy was accomplished under
between August 2008 and December 2010
robotic control. The procedural time, blood loss, length of stay and short term
outcomes are similar to those reported for laparoscopic surgery and somewhat Results: Operation for malignant pathology was 90% and 75% for hand-assisted
improved compared to open surgery as described in the literature. laparoscopic group and robot-assisted laparoscopic group, respectively. Two
patients in hand-assisted laparoscopic group needed open conversion. There
This case may be the first reported robotic resection of a Duodenal GIST
was no significant difference in mean operating time (315.4 vs. 550.8 minutes),
tumor. Additionally, Duodenal resection is a viable option for management of
median blood loss (200 vs. 175 ml), pancreatic fistula rate (30 vs. 37.5%),
GIST tumors and should be further studied as the benefits of robotic control on
bleeding complication rate (30 vs. 0%) and procedure related mortality rate (0
duodenal resection and reconstruction may be seen in future procedures.
vs. 0%). There was a significant shorter mean hospital stay (33.6 vs. 11.1 days)
P046: COMPARISON OF SUTURING TASKS USING THE DA VINCI in robot-assisted laparoscopic group. There was no significant difference in R0
SINGLE-SITE INSTRUMENTS SYSTEM AND LAPAROSCOPIC SINGLE surgical margin rate (100% vs. 83.3%) for patients with malignant disease.
SITE INSTUMENTS Tamas J Vidovszky, MD, Bernadette Guiroy, MD, Dan Conclusion: Robot-assisted laparoscopic approach was feasible, and safe. Robot-
Eisenberg, MD, James Lau, MD, Homero Rivas, MD University of California, assisted approach also has the advantage of lower complication rate and shorter
Davis Medical Center, Sacramento, CA; Salinas Memorial Hospital, Salinas, hospital stay than hand-assisted laparoscopic approach.
CA; Stanford School of Medicine, Palo Alto, CA
Background: Single site laparoscopic surgery has been established for P048: REVISION OF NISSEN FUNDOPLICATION TO ROUX-EN-Y
GASTRIC BYPASS WITH THE ROBOTIC SYSTEM DA VINCI. HC Pappis,
cholecystectomies, appendectomies, nephrectomies, and various other
MD PhD FACS, N Pararas, MD PhD, D Kotsakou, MD ’Hygeia’ Hospital,
procedures. One of the most important shortcomings of single site laparoscopic
Athens, Greece
surgery is the difficulty with triangulation. Laparoscopic suturing is a highly
advanced skill with a steep learning curve. Suturing with single port system Introduction: We present a case of a morbidly obese patient with BMI 42, who
poses significant difficulty, requiring conversion to traditional multiport had previously undergone laparoscopic Nissen fundoplication, successfully
laparoscopy or open surgery. We compared laparoscopic single site suturing treated by robotic assisted revision to Roux-Y-gastric bypass. We discuss our
with the da Vinci Single-Site Instruments and Accessories (dVSS) system under initial experience.
clinically simulated conditions. Methods & Procedures: The 60-years-old female patient presented to us one year
Material & Methods: Five surgeons with single site laparoscopic and robotic ago with morbid obesity, hypertension, lower limbs edemas, arthritis and
experience performed suturing tasks utilizing the dVSS system as well as manual recurrent gastroesophageal reflux. She had undergone laparoscopic Nissen
single incision laparoscopic surgery. The suturing tasks were performed on fundoplication 10 years previously, with a BMI 32 at that time. Important
explanted animal tissue. A 5 cm long longitudinal incision was made on porcine steps of the procedure included lysis of all adhesions between the liver and
small bowel. The participant had 20 minutes to complete a running suture the stomach, dissection and freeing of the wrap from the crura and the
to close the opening. Following the closure a leak test was performed. Each esophagus, repair of the wide hiatus and complete unfolding of the stomach.
participant had performed two separate suturing using single site laparoscopic Following that, we created a small gastric pouch and proceeded with the
suturing with instruments of their choice, and two separate suturing using the gastrojejunal linear side-to-side anastomosis and the completion of the
dVSS system. Beside the participant demographics, the time to completion of procedure. Operative time was 4 hours and 14 min and postoperative course
the task was measured and leak rate was evaluated. was uneventful. The patient was discharged on day 5. At one year follow up
the excess weight loss is 77% with complete recession of co-morbidities and
Results: The 5 participants (four men and one woman), ranging from 38 to 56
good general condition.
years of age, having between 3 to 18 years of surgical experience and having
performed between zero and 80 da Vinci surgical procedures in the last two Conclusions: The conversion of a Nissen fundoplication to RYGB is always
years. All participants had previously undergone standard da Vinci Si and Single- a challenge to the surgeon. This difficult procedure is facilitated with the
Site training. All participants had some experience with laparoscopic single Da Vinci Robotic System, which allows better visualization and improved
site surgery. All 5 participants were able to complete both separate suturing manipulation in a confined space like the gastroesophageal junction of an
and a leak free closure of the enterotomy using the dVSS system in the allotted obese patient. From this initial experience, we believe that the robotic system
time. Conversely, only 3/5 (60%) surgeon was able to complete the task in will improve outcomes and lower postoperative complications in such redo
the allotted time using laparoscopic single site instruments. Furthermore the operations.
leak rate was high in this group: 90% (9 out of 10). All participant expressed
difficulty or fatigue while performing the laparoscopic task. P049: ROBOTIC VERSUS LAPAROSCOPIC ROUX-EN-Y GASTRIC
BYPASS: META-ANALYSIS Sheraz R Markar, MRCSEng MAcantab, Alan P
Conclusions: The study has demonstrated significantly improved suturing Karthikesalingam, MRCSEng MACantab, Sri Thurumathy, MBBS, James
capability using the da Vinci Single-Site Instruments and Accessories (dVSS) Kinross, MRCSEng PhD, Paul Ziprin, FRCS PhD Academic Surgical Unit, St
system compared to laparoscopic single site suturing. Although the number of Mary’s Hospital, Imperial College, UK
participants was low, it appears that the learning curve of robotic single-site
suturing is fast; all participants were able to complete the suturing tasks for their Introduction: Laparoscopic Roux-en-Y Gastric Bypass (LRYGB) is a well-
first trial. The dVSS system has the potential to expand single site surgery to practiced surgical treatment option for morbid obesity. However several
complex procedures currently not performed with single site technique because limitations such as non-articulating rigid instruments, poor ergonomics and
of the difficulty with suturing. Further comparative studies should be performed two-dimensional visualization are attributable to this technique. Robotic
with dVSS after it becomes commercially available. surgery provides increased dexterity, improved ergonomics and a true three-
dimensional and magnified view of abdominal anatomy. However, there is a
www.mirasurgery.org 47
Poster Abstracts
paucity of comparative evidence to highlight the clinical advantages of robotics Conclusion: Robotic cholecystectomy seams to be the only available training
in Roux-en-Y gastric bypass. The aim of this study was to provide pooled procedure, that will make the surgeon and the whole team feel comfortable
analysis of individually small trials comparing robotic RYGB (RRYGB) with with the robotic system, allowing lowering of all operating times, minimizing
standard laparoscopic RYGB (LRYGB). accidental moves that may cause complications, understanding of the port
positioning that is relatively different than standard laparoscopy and establishing
Methods: A systematic literature search of Medline, Embase and Cochrane
good communication between the console surgeon and the rest of the team.
Library databases was performed. The search terms “Roux-en-Y”, “Gastric
Formal fellowship training opportunities for robotic general surgery have to be
Bypass”, “Obesity”, “Robotic Surgery” and MeSH headings “Gastric
established, so as to facilitate the application of robotics directly to advanced
Bypass”(MeSH), “Laparoscopy”(MeSH), “Obesity”(MeSH), and “Surgery,
cases, where the advantages of the system are obvious.
Computer-Assisted”(MeSH) were used. The electronic search was
supplemented by a hand-search of abstracts from the European Association for P051: DYSFUNCTION OF THE DA VINCI SURGICAL SYSTEM DURING
Endoscopic Surgery, the Clinical Robotic Surgery Association, the Minimally 260 VARIOUS ROBOTIC PROCEDURES. Francois Pugin, MD, Bucher Pascal,
Invasive Robotic Association, the Surgical Research Society, the Society of MD, Buchs Nicolas, MD, Hagen Monika, MD, Morel Philippe, MD University
Academic and Research Surgery, the Society of American Gastrointestinal Hospitals Geneva, Switerland
and Endoscopic Surgeons and the Association of Surgeons of Great Britain
and Ireland. Reference lists of all relevant studies and the Current Controlled Introduction: The Da Vinci Surgical system is a complex robotic device that offers
Trials Register were reviewed. Selection criteria comprised randomised stereoscopic vision and 7 degree of freedom instruments for minimally invasive
controlled trials or comparative studies comparing robotic and laparoscopic surgery. Study aim is to evaluate system malfunctions during surgery.
Roux-en-Y gastric bypass in adults. Primary outcome measures were the Methods: From January 2006 and December 2010, a total of 260 robotic
incidence of anastomotic leak and anastomotic stricture. Secondary outcome surgeries were performed in the division of visceral surgery in our institution.
measures were post-operative complications, operative time and length We analyze retrospectively a prospective database. Dysfunctions were classified
of hospital stay. The weighted mean difference (WMD) was calculated for in two groups: robot and instrument malfunctions. Robot failures were
continuous variables and pooled odds ratios (POR) for discrete variables using then divided in console, arms, optic and system malfunctions. Instruments
random-effects models. Heterogeneity was assessed by Cochran’s Q statistic malfunctions were subclassified according to the type of the instruments.
and the Egger test was used to detect bias. Conversion to open and/or laparoscopy were evaluated.
Results: The literature search retrieved 7 publications for inclusion in this Results: A total of 11 failures from 260 procedures were noted (4.2%).
analysis. In total there were 1686 patients included in the analysis; 1093 LRYGB There were 3 instrument failures and 8 robot dysfunctions. All instrument
and 593 RRYGB. Primary outcome analysis revealed no difference between dysfunctions concerned the ultrasonic coagulation device and were solved
the groups in the incidence of anastomotic leak (POR=0.49; 95% C.I.=0.17 during the operation by instrument replacement. The robot malfunction was
to 1.38; P=0.18). However there was a significantly reduced incidence of related to the arms in 4 cases, due to inadequate position of the adapter between
anastomotic stricture in the robotic group (POR=0.43; 95% C.I=0.19 to 0.98; the arm and the instruments. Repositioning the adapter solved the dysfunction
P=0.04). Secondary outcome analysis revealed no significant difference between in all cases. There were 2 minor console dysfunction related the audio control.
the groups in the incidence of postoperative complications (POR=0.79; 95% No system error was reported. One of the two optic malfunctions led to a
C.I.=0.50 to 1.26; P=0.32), operative time (WMD=6.37; 95% C.I.=-4.30 to laparoscopic conversion (0.4%), due to light source failure.
17.04; P=0.24) and length of hospital stay (WMD=0.18; 95% C.I.=-0.52 to
0.87; P=0.62). Conclusion: The rate of malfunction during robotic visceral surgery is low
and can be solved peroperatively in many cases allowing to the surgery to be
Conclusion: This pooled analysis of comparative studies demonstrated similar completed safely. Critical failure is very uncommon but can lead to conversion
outcomes for robotic and laparoscopic Roux-en-Y gastric bypass. However, to either laparoscopy or open surgery.
the incidence of anastomotic stricture was reduced with RRYGB compared to
LRYGB over a minimum follow-up period of 6 months, thus demonstrating P052: ROBOTIC-ASSISTED LAPAROSCOPIC TREATMENT OF LIVER
the potential benefit of RRYGB. A possible reason for this reduced stricture CYSTS Daniel Langer, Miroslav Ryska, Jiri Pudil, Eva Laszikova Surgery
rate associated with robotic gastric bypass could be the technical benefits of Department, 2nd Faculty of Medicine, Charles University and Central Military
improved 3-dimensional visualization and better ergonomics allowing for more Hospital Prague, Czech Republic
accurate tissue apposition during anastomosis. This pooled analysis serves
as evidence of the benefit of robotics in Roux-en-Y gastric bypass, however Objective: Hepatic cysts do not fall into common disease group in the middle
further randomized controlled trials on this topic will help to elucidate further Europe. There are non-parasitic cystical lesions in nearly all of the cases. Only
differences in clinical outcome. minor part of patients with cystical liver masses suffer from clinical disorders
and vindicate surgery treatment. The authors intention is a short-period results
P050: ROBOT-ASSISTED CHOLECYSTECTOMY AS A BRIDGE TO presentation of robot-assisted liver cyst surgery.
ADVANCED ROBOTIC PROCEDURES HC Pappis, MD PhD FACS, N Method: Group retrospective evaluation of 12 patients, who underwent
Pararas, MD PhD, D Kotsakou ’Hygeia’ Hospital, Athens, Greece minimally invasive operative treatment for symptomatic hepatic cyst disease in
Introduction: The value of robotics in general surgery may be for advanced our surgery department.
minimally invasive procedures. The learning curve of these procedures is Results: Group of our patient was composed of 9 women (75 %) and 3 man (25
quite long, and there are very few opportunities to get familiar with the %), average aged 60 years, in range of 40 to 72 years. All operative procedures
robotic system. As a result, most surgeons currently develop robotic skills in were finished in laparoscopic way. Operation duration time averaged 125
practicing with simple routine operations, such as cholecystectomy. Our goal is minutes. There were only symptomatic cyst masses in our group, localized in
to determine whether robotic cholecystectomy is a safe and effective bridge to the right hepatic lobe in one half of cases. Cholecystectomy was accomplished
advanced robotics in general surgery. in three patients simultaneously. We have recorded 1 early complication.
Methods & Procedures: Before performing advanced robotic procedures, 2 surgeons Blood losses were negligible with no need of any blood transfusion product
had completed the Intuitive Surgical da Vinci training course and agreed to substitution. We revealed just 3 recurrences after operation of our patients. The
work together on all procedures. We report on 25 consecutive cases of robot average follow-up time was 38 months.
assisted colecystectomies, including scheduled operations and emergency acute Conclusion: Our laparoscopic liver cyst (polycystosis excepted) surgery experience
cholecystitis ones. The console surgeon and the trained assisting surgeon where supports and advocates laparoscopic treatment to be useful modality with minimal
always the same. morbidity and mortality in concordance with literature conclusions. Da Vinci
Results: We studied the cases controlling the time to docking, the operative robotic system has notably assisted in less accessible hepatic segments. Presented
time, the possible complications due to the new technique and the efficacy of the results of our group are comparable with other published conclusions. We rate our
surgeon performing the procedures at the end of the series. results as temporary considering short term trial.

48 6 TH ANNUAL MIRA CONGRESS May 11-13, 2011


P053: TRANSVAGINAL NATURAL ORIFICE TRANSLUMINAL best electrodes position for every patient, train the patient, and design a simple
ENDOSCOPIC SURGERY (NOTES)- AN OVERVIEW Christina Delimpalta, adaptable personalized socket which will properly fit every patient and the
Archontis Zampogiannis National and Capodistrean University of Athens electrodes will be automatically in contact with the optimum transmitter points
Medical School and 1st Surgical Clinic, Laikon Hospital, Athens, Greece above the skin.
Introduction: Natural orifice transluminal endoscopic surgery (NOTES) represents Electronic circuits contain components that enable suitable bioelectric signal
the future in minimally invasive surgery. With laparoscopy proving hugely acquisition and an ideal stage filters to reduce environmental and biological
effective in management of many surgical conditions with better patient outcomes, noise. The signal amplified and filtered, manipulates in the power amplifier
the prospective of scarless, painless operations with minimal complications is stage, the motor through an “H” bridge to achieve the movement of the clamp.
alluring to patients and surgeons alike. So far NOTES procedures have been The clip has been equipped with surface pressure sensory in order to feedback to
performed mostly in animal models. Clinical cases are few. Transvaginal NOTES the system so as to achieve better control and manipulation of objects. A novel
seems to currently be the most widely used, and this paper reviews published PVDF MEMS slip sensor is designed and presented.
literature on transvaginal NOTES procedures in humans. This work presents the complete development of a myoelectric prosthesis,
Methods & Procedures: Review of published literature. showing progress in the functional integration of these technologies, achieving a
high quality system technology and a relatively lower cost.
Results: NOTES is a technique allowing endoscopes to enter the abdominal
cavity through the viscera. Transgastric, transrectal and transurethral It is remarkable for the development of this design, that it is possible to
approaches have been used, but the transvaginal route remains most promising. achieve better sensitivity results than the commercially available sensors
It has been used safely by gynecologists for awhile and has none of the inherent (20-30 pC/N), since the shapes of the pyramids provide theoretical better
problems of transgastric approach such as danger of fistulization, peritonitis mechanical performance when measuring the shear forces. Since the material
or gastrostomy leakage. Advantages include minimal or no scarring, less PVDF is a material available in the actual market and with a low cost ratio, the
post-operative pain, better patient mobilization, low risk of herniation or implementation of this sensor will help to provide high technology to any social-
dermal wound complications and less adhesion formation. It is safe for obese economic status.
patients and those with abdominal wall malformations. Hybrid NOTES is the The signal obtained from the slip sensor could be then used to automatically
combination of transvaginal and laparoscopic techniques, while Totally NOTES control de oppression of the gripper with the object being handled.
is performed without abdominal wall penetration. The most widely performed
operation is NOTES cholecystectomy, mainly because it is the most feasible With this smart automatic slip control system, it is then possible to reduce de
operation in which rigid laparoscopic tools can be used. Most surgeons place training timing for a new user of a prosthetic hand.
an umbilical trocar to create the pneumoperitoneum and facilitate gallbladder Since we have an array of sensors, with a special pyramid shape, the sensitivity
mobilization, while removing the organ through the colpotomy. Totally could then overcome the problems of this kind of sensors commonly used.
NOTES cholecystectomy has been reported using two endoscopes via vaginal
incision. However, most surgeons advocate use of hybrid NOTES to ensure The tests show sensitivity improvement, as well as integration of the sensor to
operation safety until appropriate tools are manufactured, especially in abdomes the electronics of the system, the autonomous of the movements and finally the
with adhesions from previous operations. Other operations performed using field tests.
NOTES include appendectomy and peritoneal tumor staging, while hybrid and In the field of BioMEMS there are several opportunities in the biomedical field,
totally NOTES nephrectomies have also been reported. Transperitoneal and such as adapt this kind of sensors for sensible quirurgical robots. Whit the
retroperitoneal adrenalectomies and pancreatectomies have been performed in biomaterials used in this sensor, this kind of systems can be successfully applied
pigs and, if safely applied to humans, will minimize the need for dissection or in the medical field.
retraction of the surrounding organs and allow direct access with less systemic
risk. NOTES’ most important disadvantage is the lack of appropriate tools. P055: IN SILICO EXPERIMENTAL MODEL OF AN ASSEMBLING
Flexible endoscopes are not easily used in the peritoneal cavity and use of RECONFIGURABLE MODULAR MICRO-ROBOT FOR NOTES SURGERY
laparoscopic tools leads to instrument collision and inadequate exposure and Apollon Zygomalas, MD MSc, Konstantinos Giokas, MSc, Dimitrios Koutsouris,
tissue handling. Development of Magnetic Anchoring and Guidance System Prof University of Patras, School of medicine, Postgraduate Course in Medical
(MAGS) with instruments deployed intra-abdominally and maneuvered Informatics
by external magnet promise to provide solutions. Although relatively safe,
transvaginal NOTES still caries risk of bowel perforation, herniation, Introduction Natural orifice transluminal endoscopic surgery (NOTES) is
postoperative infection, visceral lesions and adhesions. With no long-term currently the most interesting achievement of surgery. Micro-robots can be used
follow-up dyspareunia, infertility, and spread of pre-existing endometriosis in NOTES in order to approach intra-abdominal organs. The objective of our
represent potential complications and many surgeons advocate NOTES use only study is to develop and simulate in silico an assembling reconfigurable modular
in women who desire no further pregnancies. Other reported complications micro-robot which could be used in NOTES surgery.
include vulvar laceration, Douglas pouch abscess and subhepatic collection. Methods & Procedures: A professional robot simulation application (Webots
Conclusions: NOTES is emerging as a breakthrough evolution in surgery. Its PRO 6.0) has been used for the development, programming and simulation of
theoretical advantages are many, but so are the difficulties to be overcome. It is the micro-robotic system. Simple design with basic 3D objects and motion-
accompanied by its own, method-specific set of problems that must be addressed mechanical characteristics have been used. Physics algorithms and motion
and resolved before it gains widespread approval. properties have been evaluated.
Results: Our experimental micro-robot consists of small subunits that can be
P054: NOVEL SLIP AND TACTILE SENSOR SYSTEM ON A MIOGRIPPER swallowed or enter throughout the natural human orifices into the abdominal
Luis Gerardo Sanchez Stone, MSc, Abel Ronquillo, MSc UPAEP, ERGOSOLAR, cavity of the patient. The subunits are been assembled in order to build a
LAAR L. G. Sánchez reconfigurable modular micro-robot. Three kinds of subunits have been
Novel myoelectric hand prosthesis design with MEMS slip sensors. developed; an endoscopic subunit, a surgical instrument unit and a body unit.
Two types of robots can be assembled depending on the kind of the frontal
Abstract— The hand design is based in a three-digit clip that allows to perform subunit (endoscopic robot, surgical instrument robot). A modular remote
flexion and extension movements manipulated by myoelectric signals coming controlling system has be used in order to control the robot which operates in
from the muscle: radial extensor and radial flexor. Pronation and supination the abdominal cavity. Using this controlling system approach the position of
movements of the wrist are manipulated manually by a circular adapter that each subunit of the modular micro-robot is always visibly known. The controller
performs the interconnection between the hand and the socket to give it a fixed helps the surgeon to try different formations for his robot without changing
alignment. the formation of the micro-robot itself. Although the formation of the modular
With respect to the electrodes that transmit the myolelectric signals, those were micro-robot is always known, its intrabdominal position and orientation is not
inserted in the patient socket to avoid problems finding the exact location of the always predictable. In order to achieve satisfactory motion and operational
signal transmitter muscle. Through an special software, it is possible to find the abilities more than 3 body subunits should be used.

www.mirasurgery.org 49
Poster Abstracts
Conclusions: Our experimental modular micro-robot model can serve as the basis difficult to achieve using manual instrumentation. A new technology has been
for the development of a more complex micro-robotic system which can be used developed using haptic robotics that replaces traditional UKA instrumentation.
in NOTES surgery. The novel approach of modular remote controlling system This study compares the accuracy of UKA component placement with
can facilitate the improvement of controlling systems for complex robots and the traditional jig-based instrumentation versus robotic guidance.
development of sophisticated remote modular micro-robot controllers. Since the Methods: 85 UKAs performed using standard manual instrumentation were
live human organism cannot be easily simulated there is the need of an in vivo study. compared to 67 performed with a robotically guided implantation system
without instrumentation. Each was performed using a minimally invasive
P056: SOFIE, A ROBOTIC SYSTEM FOR MINIMALLY INVASIVE SURGERY
surgical approach. The two groups were identical in terms of age, gender
Linda Van den Bedem, dr ir, Ron Hendrix, ir, Gerrit Naus, dr ir, Ruud Van der
and BMI. The coronal and sagittal alignment of the tibial components were
Aalst, ir, Nick Rosielle, dr ir, Henk Nijmeijer, prof dr, Jos Maessen, prof dr,
measured on pre- and post-operative AP and lateral radiographs. Postoperative
Ivo Broeders, prof dr, Maarten Steinbuch, prof dr ir Eindhoven University of
tibial component alignment was compared to the pre-operative plan.
Technology, the Netherlands, Academic Hospital Maastricht, the Netherlands,
Meander Medical Center Amersfoort, the Netherlands Results: The RMS error of the tibial slope was 3.7° manually compared to 1.2°
robotically. In addition, the variance using manual instruments was 9.8 times
Developments in surgery are aimed at increasing patient value by improving
greater than the robotically guided implantations (p<0.0001). In the coronal
the efficacy of procedures and decreasing patient trauma. In line with these
plane, the average error was 3.0 ± 2.2° more varus using manual instruments
developments, surgeons nowadays employ robotic systems for minimally invasive
compared to 0.3 ± 1.9° when implanted robotically (p<0.0001), while the
surgery (MIS). At the Eindhoven University of Technology, the Netherlands,
varus/valgus RMS error was 3.7° manually compared to 1.8° robotically. The
Sofie is developed, a new robotic system for minimally invasive surgery. The
average depth of medial tibial plateau resection was significantly less with inlay
system provides haptic feedback, precision, a compact design and high dexterity,
tibial components (3.9 ± 0.9mm) relative to onlay tibial components (6.8 ±
enabling a further increase in patient value.
0.9mm, p<0.0001). In addition, a significantly higher percentage of robotic
Sofie is a so-called robotic master-slave system, shown in the figure. The master inlay patients went home the day of surgery (12% vs. 1%, p<0.0001).
is operated by the surgeon, thus controlling the slave robot, which in turn
Conclusion: Tibial component alignment in UKA is significantly more accurate
manipulates the instruments. Two pen-shaped handles form the interface to the
and less variable using robotic guidance compared to manual, jig-based
surgeon. In combination with visual feedback, the interface creates an intuitive
instrumentation. By enhancing component alignment, this novel technique
working environment by virtually placing the hands of the surgeon on the
provides a potential method for improving outcomes in UKA patients.
instrument part inside the patient. The surgeon’s hand movements are measured
using high-resolution encoders, enabling accurate control of the slave robot P058: SLEEVE GASTRECTOMY FOR MORBID OBESITY WITH THE
movements. A motor for each degree of freedom in a handle of the interface USE OF THE DA VINCI SURGICAL SYSTEM. A. Alexandrou, Ioannis
provides haptic feedback of the instrument force to the surgeon. Where possible, Papanikolaou, D. Diamantis, N. Dimitriou, N. Mpasios, J. Griniatsos, A.
a direct drive minimizes friction [1,2]. Giannopoulos, Theodoros Diamantis 1st Department of Surgery of the
Developments in robotic MIS often focus on compliant mechanisms for the University of Athens, Laiko Athens General Hospital, 17 Agiou Thoma St,
slave robot, complicating dynamic force measurements required for haptic 11527, Athens, Greece.
feedback. In contrast, the basis of the Sofie slave consists of a pre-surgical setup Background: Laparoscopic sleeve gastrectomy (LSG) is used with increasing
that is rigidly connected to the operating table. A platform is positioned above frequency for the treatment of morbid obesity. Robotic techniques have been
the patient. From the platform, the robotic arms manipulate the individual mainly used for the performance of Roux-en-Y gastric bypass. We report herein
endoscopic instruments with respect to the patient. This layout leads to a short our experience with LSG performed with the use of the Da Vinci surgical system.
and stiff force-path between the instruments, as well as between the instruments
and the operating table. The short and stiff force-path is advantageous for Methods: Twenty-three consecutive patients underwent LSG with the use of the
the dynamic system behavior. Accurate force measurements used for haptic Da Vinci surgical system. Surgical techniques followed the principles of standard
feedback, facilitate high accuracy handling up to 10 Hz. LSG. Preparation of the stomach was performed by the console-surgeon and its
division with the staplers by the patient-side surgeon.
Furthermore, the layout results in a compact, lightweight and robust design.
The compactness of the design improves access to the patient during surgery and Results: Nineteen women and four men with a mean body mass index (BMI)
reduces the system mass considerably. Moreover, the system is easy to handle of 48.3 kg/m2 were operated. Mean operative time was 95.8 +/- 11.2 min.
and pre-surgery setup of the system can be done quickly. Finally, an ’elbow- Docking time was 16 +/- 4.1 min. There were no conversions. Peri-operative
wrist’ configuration at the tip of an instrument provides high dexterity in the morbidity and mortality was zero. Time to BMI ratio for robotic LSG was 2 +/-
surgical area, reducing deflection of the external manipulating arm [3]. 0.4 min/kg/m2 and it was equal to the respective of our standard LSGs. When
the docking time was excluded, the same ratio was 1.6 +/- 0.1, significantly
To date, a proof-of-concept of the slave and a preliminary master are available. shorter than the respective 2.1 +/- 0.5 of our conventional LSGs (p = 0.016).
Furthermore, a hardware cabinet with software is available, enabling control Mean excess body weight loss 1 year post-operatively was 66.4 +/- 25.2%.
of the slave robot using the master. Haptic feedback to the surgeon is developed
further after successful preliminary tests with the team surgeons. Completion of Conclusions: Robotic laparoscopic sleeve gastrectomy is a feasible, safe, and
the proof-of-concept is scheduled for mid-2011. efficient surgical technique for the treatment of morbid obesity. The use of the
Da Vinci increases the self-confidence of the surgeon thus reduces the pure
[1] R. Hendrix, P.C.J.N. Rosielle and H. Nijmeijer (2009), Design of a haptic operative time of the procedure.
master interface for robotically assisted vitreo-retinal eye surgery, Int. Conf.
Adv. Robot., pg. 1-6. P059: CAN TOTALLY ROBOTIC LAPAROSCOPIC GASTRIC BYPASS
[2] J.H. Grasman (2008), Mechanical design and construction of a 5 DOF haptic FOR MORBID OBESITY PRECISELY DUPLICATE ANY TRADITIONAL
master device for an eye-surgery robot, Technical report, DCT 2008.111, LAPAROSCOPIC TECHNIQUE? A. Alexandrou, Ioannis Papanikolaou,
Eindhoven University of Technology. D. Diamantis, N. Dimitriou, N. Mpasios, J. Griniatsos, A. Giannopoulos,
Theodoros Diamantis From the 1st Department of Surgery of the University
[3] L.J.M. van den Bedem (2010), Realization of a demonstrator slave for robotic of Athens, Laiko Athens General Hospital, 17 Agiou Thoma St, 11527, Athens,
minimally invasive surgery, Ph.D. thesis, Eindhoven University of Technology. Greece
P057: ROBOTICALLY ASSISTED UKA IS MORE ACCURATE THAN Background: Laparoscopic RYGBP for morbid obesity is a demandino operation.
MANUALLY INSTRUMENTED UKA Thomas M Coon, MD, Matthew Robotic techniques have been shown to ameliorate the technical difficulties
D Driscoll, MD, Sharon Horowitz, BS, Michael A Conditt, PhD St Helena’s thus causing a reduction of the peri-operative morbidity, mainly by simplifying
Hospital, Scott and White Memorial Hospital, MAKO Surgical Corp the construction of the gastrojejunal anastomosis (GJ). Robotic LRYGB has
been reported either as totally robotic with manual suturing of the GJ or as
Introduction: Successful clinical outcomes following unicompartmental knee
robotically assisted with the use of the robot only for the GJ. We report a series
arthroplasty (UKA) depend on accurate component alignment, which can be
of totally gastric bypass patients with semi-manual GJ.
50 6 TH ANNUAL MIRA CONGRESS May 11-13, 2011
Patients & Methods: Nine consecutive paients underwent totally robotic LRYGBP. P061: RESULTS OF A PROFICIENCY-BASED CURRICULUM WITH THE
The GJ was fashioned with a combination of use of the linear stapler and manual VIRTUAL REALITY ROBOTIC SURGERY SIMULATOR: DV-TRAINER.
suturing. Perrenot Cyril, Perez Manuela, MD, Tran Nguyen, MD, Hubert Jacques, MD
CHU de Nancy
Results: Mean preoperative BMI was 45.3 +/- 4.7 Kg/m(2). In one case we had to
undock the Da Vinci Surgical System at the time of the jejunojejunostomy due to Objective of the Study: Development of robotic surgery involves training and
unfavourable ergonomic. Mean time to dock the robot was 16.3 +/- 3.5 minutes assessment of specific skills. Training on animal model or in operating room is
while mean total operative time was 197.2 +/- 12.3 minutes. Immediate expensive and expose to medico-legal implications of learning curve. Virtual
postoperative morbidity and mortality equalled zero. The mean EWL rate one- reality simulators are an interesting alternative, already use in laparoscopy
year post-op was 79 +/- 15%. since many years but still under development for robotic surgery. The aim of
this study is to define the learning curve and time needed for a proficiency-
Conclusion: Totally robotic LRYGBP can duplicate precisely any conventional
based curriculum on the dV-Trainer (MIMIC Technologies®), a virtual robotic
technique without any compromise in operative time, short- or long- term results.
surgery simulator.
P060: REMOTE TELE SURGERY : HELP OF LOSSY VIDEO Methods & Procedure: Prospective study, from December 2010 to Februar 2011,
COMPRESSION FOR THE FUTUR Manuela Perez, MD, Nedia Nouri, Jean- using three robotic surgery simulators dV-Trainer set up in our school of
Marie Moureaux, Denis Abraham, Michel Dufaut, Jaques Hubert, PhD Centre surgery. 14 surgeons (all beginners in robotic surgery, less than 5 cases) were
de Recherche en Automatique de Nancy, Nancy-Université, CNRS 2, avenue de recruited. Twenty-two exercises divided in six levels were included. All subjects
la forêt de Haye, 54516 Vandœuvre-lès-Nancy, France 2 Centre de Recherche performed the exercises in the same order and were allowed to start next
en Automatique de Nancy, Nancy-Université, CNRS Faculté des Sciences, BP exercise only when they rise proficiency (defined as 90% of the expert level).
70239, 54506 Vandœuvre-lè The analysis was based on 3499 scores of the simulator.
Introduction: Progress of robotic-assisted surgical techniques allows today Results : All subjects were able to complete the twenty-two exercises of the
mini-invasive surgery to be more accurate, providing benefits to patients training program until proficiency level. They needed between 5 to 12.2 +/- 3.3
and surgeons for complex surgical procedures. Remotes telesurgery are hours to finish it. The mean number of attempt for each exercises was 11.4 +/-
sporadically described since 2001 with the "Operation Lindbergh". The 3.8 attempts. The mean time for one exercise was 154.2 sec +/- 19.5 sec.
medical video from the da Vinci? represent a high requires significant
Conclusions: Using a proficiency-based training program for dV-Trainer is highly
bandwidth. An appropriate solution to reduce the amount of data could be
feasible and the mean time to rise proficiency is achievable during a residency
found among the various existing lossy compression schemes. The aim of this
training program. The robotic surgery simulator is a valid tool for robotic training.
study is to determine the compression threshold tolerated by surgeon in an
application of telesurgery through a subjective assessment of the quality of P062: ACCURACY OF ROBOTICALLY ASSISTED ACETABULAR CUP
video encoded using the MPEG2 algorithm. IMPLANTATION Douglas E Padgett, MD, Lawrence D Dorr, MD, Miranda
Methods & Procedures: We design a study based on surgeons’ evaluation of L Jamieson, MS, Michael A Conditt, PhD Hospital for Special Surgery, Good
compressed surgical video from the da Vinci using the Double-Stimuli Samaritan Hospital, MAKO Surgical Corp
Continuous Quality Scale (DSCQS) from the International Telecommunication Introduction: Recent gains in knowledge reveal that the ideal acetabular cup
Union (ITU-R BT-500-11 recommendations) that give the general test viewing position is in a narrower range than previously appreciated and that position
conditions for subjective assessment of the quality of television pictures. The is likely different based on femoral component anteversion. For that reason
DSCQS is base on the comparison between a native video reference A and the more accurate acetabular cup positioning techniques will be important for
same video compressed B. This video sequences A and B are presented to the contemporary THA. It is well known that malalignment of the acetabular
surgeon. For each pair he give a’quality score’ by marking on a continuous line. component in THA may result in dislocation, reduced range of motion or
The line is divided into five equal lengths ranging from Excellent’ to ’Bad’. accelerated wear. Up to 8% of THA patients have cups malaligned in version by
The scores obtained by each sequence were processed as the difference in more than ±10º outside of the Lewinnek safe zone. This type of malalignment
judgment between reference and impaired sequences. Seven robotic surgeons may result in dislocation of the femoral head and instability of the joint within
were involved in the sudy. Four sequences were selected from several typical the first year, requiring reoperation. Reported incidences of reoperation are
surgical operation cases submitted at many sequences Bit-rates from 1,02 to 1-9% depending on surgical skills and technique. In addition, cup malalignment
8,04 Mbits/s. Sequence 1 represents a surgical laparoscopic instrument motion; is becoming increasingly important as adoption of hard on hard bearings
Sequence 2 a blood clotting with a bipolar forceps; Sequence 3 a fat area and increases as the success of large head hard on hard bearings seems to be more
Sequence 4 a compress application. The video sequences were displayed to sensitive to cup positioning. This study reports the accuracy of a haptic robotic
observers thanks to the viewing facilities of the robotic-assisted console in the system to ream the acetabulum and impact an acetabular cup compared to
operating theatre typical conditions. manual instrumentation.
Results: Sequences 2 and 3 appeared to be non critical. Hopefully, sequences 1 Methods: Six fresh frozen cadaveric acetabula were CT scanned and three-
and 4 allow us to determine regression curve, with coefficient of determination dimensional templating of the center of rotation, anteversion and inclination of
corresponding to the dispersion of points compared to the curve provides at the cup was determined pre-operatively. Half of the specimens were prepared
R²=0.6245 (sequence 1) and R²=0.9117 (sequence 4). These values show a good with manual instrumentation while half were prepared with robotic guidance.
homogeneity between assessors. This regression curve allow us to identify, with Haptic and visual feedback were provided through robotics and an associated
a good precision, the threshold, above which no loss of quality is perceived and navigation system to guide reaming and impaction of the cup. The robot
below it only a poor quality can be expected. This threshold is 3.2 Mbits/s, constrained the orientation and position of the instruments thus constraining
above, no surgeon perceived any loss of quality due to bit-rate reduction. The the inclination, anteversion and center of rotation of the reamer, trial and
initial video requested initially 270 Mbits/s to be transmitted and it represent a the final cup. Post-operative CT’s were used to determine the achieved cup
compression ratio of around 90:1. placement and compared to the pre-operative plans.
Conclusion: One of the main results of this study is that, not only using lossy Results: In all cases, robotic guidance resulted in placement of the acetabular
compression for medical video transmission seems possible, but also one can cup within ±3° of anteversion, ±3° of relative to the pre-op plan. The average
determine a threshold above which no surgeon perceives any loss of quality absolute inclination error was 1.5±1.2° and the average absolute anteversion
with a compression ratio around 90:1. This very promising conclusion is high of error 1.3±1.4°. Cup placement with robotic assistance was significantly
importance, unlocks one of the technical locks to transmission of medical video more accurate and precise than with manual instrumentation. With manual
and opens doors to distant-teaching, distant-mentoring and soon distant-surgery instrumentation the errors were, on average, 4.2 times higher in inclination and
using network transmission. 4.8 times higher in anteversion compared to robotic instrumentation.
Conclusion: This haptic robotic system substantially improved the accuracy of
acetabular reaming and placement of the final cup compared to traditional
manual techniques. With greater knowledge of ideal acetabular cup position,
www.mirasurgery.org 51
Poster Abstracts
highly accurate techniques may allow surgeons to decrease the risk of Haptic robotic cutting tools obviously can be used with off-the-shelf prosthetic
dislocation, promote durability and improve the ability to restore appropriate components, but this approach would fail to fully take advantage of the precision
leg length and offset. Haptic robotics has proven to be safe and effective in both surfaces that can be achieved using robot assisted bone sculpting. Instead, a
knee and hip surgery and provides the potential to redefine the “instrument set” purpose built system of modular knee components can be defined that work in
used for orthopedic procedures. any combination (medial or lateral unicompartmental, bi-unicondylar, medial
or lateral plus patellofemoral, or tricompartmental), require minimum bone
P063: ACCURACY OF UKA COMPONENT PLACEMENT WITH removal, can be placed through very small incisions, give great flexibility to
DYNAMICALLY REFERENCED TACTILE ROBOTICS Nicholas D Dunbar, customize implant placement to fit the patient’s anatomy, and take advantage
MS, Martin W Roche, MD, Brian H Park, BS, Sharon Horowitz, BS, Michael A of the types of fixation features which easily are created with a robotically
Conditt, PhD, Scott A Banks, PhD Holy Cross Hospital, University of Florida, controlled bone cutting device.
MAKO Surgical Corp
The current treatment implementation and implant design will be presented.
Introduction: Unicompartmental knee arthroplasty (UKA) can achieve excellent Clinical results for unicompartmental procedures and in vitro results for
clinical and functional results for patients suffering from single-compartment multiple-compartment procedures will be presented and discussed.
osteoarthritis. However, UKA is considered to be more technically challenging
to perform, and malalignment of the implant components has been shown P065: THE LEARNING CURVE OF ROBOTIC-ASSISTED UKA Riyaz
significantly to contribute to UKA failures. It has been shown that surgical Jinnah, MD, Sharon Horowitz, BS, Tamas Erdos, BS, Michael A Conditt, PhD
navigation and tactile robotics could be used to provide very accurate Wake Forest University, MAKO Surgical Corp
component placement when the bones were rigidly fixed in a stereotactic Introduction: Successful clinical outcomes following unicompartmental knee
frame during preparation. The purpose of this investigation was to determine arthroplasty (UKA) depend on accurate component alignment, which can be
the clinically realized accuracy of UKA component placement using surgical difficult to achieve using manual instrumentation. A new technology has been
navigation and tactile-robotics when the bones are free to move. developed using haptic robotics that replaces traditional UKA instrumentation.
Methods: Complete records, including pre-op CT, post-op CT, and surgical plan Integrating new technology into the operating room can be associated with
were available for 22 knees out of the first 45 procedures performed using a a significantly long learning curve, which introduces inefficiency in to the
new tactile-guided robotic system. Three-dimensional component placement surgeon’s practice and the hospital’s OR work flow. This study quantifies the
accuracy was assessed by comparing the pre-operative plan with the post- learning curve of a new technology developed to improve the accuracy of UKA.
operative implant placement (desired versus actual). Errors were assessed as Materials & Methods: Two hundred forty four patients received a UKA performed
single axis root-mean-square (RMS) entities. five different surgeons with a robotically guided implantation system employing
Results: Femoral component RMS placement errors averaged 1.4 mm/2.6º a CT based pre-operative plan implemented using a haptic-guided burr for all
along any single axis. Tibial component RMS placement errors averaged 1.18 bone resection. Each surgeon had performed at least 30 surgeries with the new
mm/2.14º along any single axis. technology. As the philosophy of each surgeon differs in terms of tourniquet
use, the time from the insertion of the first bone pin to the acceptance of the
Discussion & Conclusion: Using traditional manual instruments, Cobb et al. found
final trial components was measured. This time frame includes attachment of
average RMS errors of 2.20mm/5.48º. Using the robotic approach with bones
navigation markers to the femur and the tibia, three-dimensional registration
fixed, Cobb et al. reported RMS errors of 1.11 mm/2.5º, directly comparable to
of actual boney surfaces to the digital reconstructions, and bone resection. The
our results with bones moving freely during surgery. These results suggest excellent
surgical time of the final 20 surgeries of each surgeon was averaged for a steady
implant placement accuracy can be achieved using tactile robotics, and suggest
state surgical time. For each surgeon, the number of surgeries required to have 2
excellent results are achieved in what typically would be considered a learning phase.
consecutive and 3 total surgeries completed within the 95% confidence interval
P064: HAPTIC ROBOTICS FOR MINIMALLY INVASIVE, MODULAR of the steady state surgical time of that particular surgeon was also noted.
KNEE ARTHROPLASTY Scott A Banks, PhD, Rony Abovitz, MS, Arthur Results: The average surgical time for all surgeries across all surgeons was 59 ±
Quaid, PhD, Jason K Otto, PhD, Michael A Conditt, PhD University of Florida, 21min (range: 27min to 165min). This includes both the learning curve cases as
MAKO Surgical Corp well as the steady state cases. The surgeon with the shortest steady state surgical
Total knee arthroplasty (TKA) has evolved over the past 40 years to a point where time averaged 43 ± 8min, while the surgeon with the longest steady state
it now is a routine treatment with fairly predictable outcomes. However, TKA is an surgical time averaged 76 ± 16min. The number of surgeries required to have
end-stage treatment which frequently is used when only one or two compartments in 2 consecutive surgeries completed within the 95% confidence interval of the
the knee are damaged. Ideally, treatments for earlier stage and isolated disease would steady state surgical time was 7 (range: 4 to 12). The number required to have
be available to provide the same high level of outcome predictability, but provide 3 surgeries completed within the 95% confidence interval of the steady state
for isolated treatment of the affected compartments, greater levels of postoperative surgical time was 8 (range: 5 to 13).
physical activity and the shorter convalescence demanded by younger, more active, Conclusions: New technology has been introduced that essentially replaces
and often employed patients. One approach to a compartment-by-compartment traditional manual instrument sets with a passive robotic arm that precisely
treatment regime is the utilization of discrete condylar unicompartmental prostheses executes a pre-operative plan.. The learning curve of this novel surgical technique
and a patello-femoral prosthesis in any combination. This approach has been is reasonable and is much shorter than has been reported with the introduction
practiced in some European clinics for decades with good reported outcomes. of other orthopedic technologies in the OR. For example, the efficiency learning
However, it remains a major surgical challenge to optimally place multiple discrete curve associated with using surgical navigation for TKA has been reported to be
arthroplasty components using conventional tools and small incisions. This lecture around 30 cases. New techniques such as hip resurfacing have been associated
will present a detailed overview of a unified approach to minimally invasive, modular with learning curves as high as 70 cases. While the surgeons in this study may
knee arthroplasty using haptic robotic instrumentation (Tactile Guidance System be classified as early technology adaptors and 2 of the 5 surgeons had previous
2.0, MAKO Surgical, top right) and implants designed specifically for robotic experience with surgical navigation, an average learning curve of 8 cases is very
installation in a customized modular treatment regime (MAKO Modular Knee, promising for the acceptance of this novel robotic-guided surgical technique.
MAKO Surgical, bottom right).
Haptic robotics provide a ’virtual cutting guide’ capability permitting precise P066: ROBOTIC SLEEVE GASTRECTOMY. AN INTERMEDIATE
sculpturing of bone surfaces using near-zero-visibility minimally invasive APPROACH TO UNDERGO TOTALLY ROBOTIC GASTRIC BY-PASS.
incisions. The use of a single-multifunctional tool eliminates many of the Ramon Vilallonga, PhD, Jose Manuel Fort, PhD, Miriam Zamora, Montserrat
instrument trays commonly needed for these procedures. The surgeon has Chinchilla, Nuria Ros, Oscar Gonzalez, PhD, Manel Armengol Carrasco, PhD
complete control in manipulating the bone cutting tool within the desired bone- Universitary Hospital Vall d’Hebron. Barcelona.
removal area, but the haptic robotics prohibit the cutting tool from removing Objective and Study Technique Novel techniques such as laparoscopic sleeve
bone outside the planned bone removal volume. Precise bone sculpturing has gastrectomy (LSG) ais now used for the treatment of morbid obesity. In fact, the
the potential to minimize bone removal and optimize the alignment and fixation only publish article to our knowledge has been inaugust 2010. There is now enough
of the prosthetic components. experience with LSG in our group and we had the possibility to begin robotic sleeve
52 6 TH ANNUAL MIRA CONGRESS May 11-13, 2011
gastrectomy. The application of robotic techniques has been reported for bariatric Initial test results using breast phantoms in a GE 3T MR system are presented
operations like laparoscopic Roux-en-Y gastric bypass and laparoscopic adjustable that demonstrate the significant advantages of the present biopsy system. In
gastric banding, and more recently (august 2010) for LSG. We report herein our addition, it is proposed that the system will be a valuable tool for ablative
initial experience with LSG performed with the use of the Da Vinci surgical system therapy using real-time MR thermometry.
as a previous step before Robotic Roux-en-Y gastric bypass.
P068: 3D VISUALIZATION AND TRAJECTORY PLANNING SYSTEM FOR
Description of the Method: Eighteen consecutive patients underwent LSG with REAL TIME INTERVENTION Mehran Anvari, MB BS PhD FRCSC FACS,
the use of the Da Vinci surgical system by the same surgical team. Surgical Bart Verzijlenberg, MSc, Julian Dobranowski, MD FRCPC, Kevin Randall,
techniques followed the principles of standard LSG. We used three 12 mm PhD Centre for Surgical Invention and Innovation; MacDonald, Dettwiler and
standard trocars and a 8mm DaVinci trocar to perform this novel technique. Associates
The 8-mm metallic robotic ports were inserted through the standard, disposable
12-mm trocars. Preparation of the stomach was performed by the console There is no doubt that automated robotics will augment diagnostic and
surgeon alone and its division with the staplers by the patient-side surgeon. We therapeutic interventions. The high precision targeting accuracy achievable by
completed a sleeve gastrectomy at 2 or 5 cm from the pylorus with a 36F boggie a robot will enhance the placement accuracy of a diagnostic or therapeutic tool
inside the stomach and performing stappeling through a standard 12 mm trocar. to the site of a detected lesion to within fractions of a millimeter. However,
A complete robotic prolene® suture for reinforcment. Also Seamguald® was although physicians are currently trained to diagnose and perform interventions
used as reinforcements. A drain is finally placed next to the sleeve. based on 2D clinical images, there are limitations in procedures such as core
needle biopsy, since needle trajectory will rarely lie in a single plane. This can
Prelinimary Results: Twenty patients (2 men and 18 women) with a mean age of make needle placement challenging when critical structures are close to the
44.4 years (17-63) and a mean body mass index (BMI) of 48.0 kg/m2 were targeted lesion. A real time 3D guidance system would be ideal, but real-time 3
operated by Robot. Mean total operative time (including docking time) was D imaging devices such as CT or MRI scanners, have limited space to perform
104.1±15.3 min. Mean set-up time was 35 minutes and mean docking time the intervention. Safety issues also limit the ability of the physician to guide the
was 6 min. There were no conversions. Complete robotic prolene® suture intervention in real time.
for reinforcement was performed in 14 patients. Also Seamguald® was used
as reinforcements in 6 patients. Peri-operative morbidity and mortality was With the development of the CSii in-bore automated image guided robotic
zero. Mean time for discharge was 4.16 days. We had a patient who required a system (described elsewhere at this conference), real time MRI and CT guided
conversion to laparoscopic gastric by-pass after one month because of an unusual intervention is now possible. Further, a system has been developed in which the
complication of curling stomach. Mean BMI at 3 months post-operatively was physician can plan the entire procedure and optimize as necessary using a virtual
35.8± 25.6%. The procedure can be completed with only one assistant and with 3D system. Early pre-clinical data indicate that this system will dramatically
four trocars instead of five in LSG. improve safety and accuracy for MRI- and CT-guided interventional procedures.
We will perform a live demonstration for 3D planning and targeting of a
Conclusions/Expectations: Robotic laparoscopic sleeve gastrectomy is a feasible suspected lesion for an automated robotic intervention.
and safe approach. In experienced laparoscopic hands it is still an efficient
surgical technique for the treatment of morbid obesity. No added operating P069: MINIMIZING HEPATIC TRAUMA WITH A NOVEL LIVER
time for the procedure has been reported. The application of robotics to RETRACTION METHOD DURING ROBOTIC AND LAPAROSCOPIC
this type of surgery might have less obvious advantages than with LRYGBP. GASTRIC CANCER SURGERY, A SIMPLE LIVER-SUSPENSION WITH
However, to our knowledge few groups use the Da Vinci system in the world. GAUZE-SUTURE TECHNIQUE Yanghee Woo, MD, Kazutaka Obama,
Our Group has considered as a novel and first approach before being involved MD PhD, Tae-Il Son, MD, Hyung Il Kim, MD, Woo Jin Hyung, MD PhD
in Robotic Gastric Bypass. Department of Surgery and Robot and Minimally Invasive Surgery Center at
Yonsei University College of Medicine
P067: DEVELOPMENT OF AN AUTOMATED REAL-TIME MR GUIDED
ROBOTIC SYSTEM FOR HIGH PRECISION DIAGNOSTIC AND Introduction: Radical gastrectomy requires prolonged liver retraction for adequate
THERAPEUTIC INTERVENTIONS IN BREAST. Mehran Anvari, MB BS PhD exposure of the hepatogastric ligament which may lead to unnecesary hepatic
FRCSC FACS, Julian Dobranowski, MD FRCPC, Kevin J Randall, PhD, Peter trauma. We offer a new minimally traumatic technique for liver retraction
Lovrics, MD FRCSC, N Konyer, BSc, T Fielding, MSc, K Morency, MSc Centre during totally robotic and laparoscopic radical gastrectomies using simple liver
for Surgical Invention and Innovation; MacDonald, Dettwiler and Associates suspension with gauze-suture technique with a comparison to the established
liver puncture method.
Contrast Enhanced (CE) Magnetic Resonance (MR) imaging has proven to
be the most sensitive imaging modality in the detection of breast cancer for Methods: We retrospectively analyzed the clinical and operative characteristics
lesions occult in conventional X-ray and Ultrasound mammography. Recently, along with the patients’ perioperative transaminases of 92 patients who
minimally invasive MR-guided biopsy techniques have been developed underwent liver puncture or liver suspension methods during gastric
to extract core samples under MR guidance as an out-patient procedure. resection in 2010 and compared the two groups. We excluded other
However, in current, commercially available, systems the procedure is patients with history of liver diseases, abnormal preoperative liver function
performed out of bore and requires the patient to be shuttled in and out of the tests, intraoperative aberrant left hepatic artery ligation, postoperative
magnet several times. Ultimately the procedure is time consuming, accuracy complications and combined operations. In brief, two 4x4 gauzes were folded
is compromised, and most importantly, target verification is lost. It has been in half and threaded with one double-armed straight needled 2-0 Prolene to
reported, for example, that as many as 8% of CE-MR guided biopsies miss create a 8 cm non-traumatic support for the liver retraction. The ports were
the target lesion. Clearly a more accurate MR guided biopsy procedure is placed as previous described for robotic (Surg Endosc 2009. 23:1204-1211)
desirable. and for laparoscopic (Eur J Surg Oncol. 2007. 33:314-319) surgeries. One of
two straight needles and the attached suture-threaded gauzes were introduced
In the current system the procedure will be performed under real time into the intraperitoneum via a 12mm trocar. The straight needle was used to
guidance with the patient remaining in the bore of the MR imager. Given the pierce the anterior abdominal wall directly above the middle of the left lobe
limited space, and the high field (magnetic and rf) environment the robotic of the liver. Then, the pars flaccida of the hepatogastric ligament was divided
system faced significant design and development challenges. The CSii device upto the right of the esophageal crus. Two plastic surgical clips (Hem-o-
is the first compact high precision system with independent linear (x,y,z) lock, Weck Pilling, NC) were used to secure the prolene suture to the pars
and angular (pitch, yaw) degrees of freedom. The positioning system and condensa. The other straight needle with the suture-threaded gauze was then
image registration method for the current device are intrinsically superior to introduced and passed externally through the abdominal wall just to the right
existing out-of-bore systems. With 5 degrees of freedom the physician is able of the falciform ligament. While the assistant slowly pulled upward on the
to select an optimized trajectory to the target lesion. The planned trajectory two sutures, the two gauzes were brought together by the pars condensa and
is overlaid on the 3D workstation display and, once confirmed, the control stretched to cover the undersurface of the retracted liver creating a V-shaped
system autonomously guides the device using redundant position sensors to liver suspension. The two external sutures are tied together to rest on the
maintain track by cross checking with MR position data. Real time guidance is abdominal wall.
critical for patient safety as well as instant confirmation of targeting accuracy.

www.mirasurgery.org 53
Poster Abstracts
Results: All liver retraction by either the liver puncture or liver suspension P071: ROBOTIC SINGLE-SITE CHOLECYSTECTOMY: THE "SINGLE"
methods were successfully completed without intraoperative complications. PORT TO THE FUTURE OF SURGERY? FIRST EXPERIENCE FROM
The patients in the liver suspension group had more non-hepatic comorbidities GREECE. Konstantinos M Konstantinidis, MD PhD FACS, Savas C Hiridis,
than those in the liver puncture group (p=0.029). Other patient MD MSc, Periklis S Chrysocheris, MD, Peter C Hiridis, MD, Michael K
characteristics such as gender, age, and BMI did not differ. There were no Georgiou, MD ATHENS MEDICAL CENTER
differences between the two groups in the number of robotic (25 vs 20, Introduction: Laparoendoscopic single-site surgery allows for the performance of
respectively) and laparoscopic (24 vs 23, respectively) approaches and total most abdominal procedures with a single small incision and minimal scarring.
mean operative times (200.3+66.9 and 214.9+74.4). The preoperative ALT The da Vinci Surgical System provides advantages of easy articulation and
(17.0+6.0 vs 15.6+4.5) and AST (18.0+3.8 vs. 17.4+ 4.5) levels between improved ergonomics; lately an interesting novel platform was presented by the
the two groups did not differ significantly. However, the patients in the liver manufacturers.
puncture group had up to 2.4 and 1.6 times greater increase in ALT and AST
levels, respectively with a longer time to normalization than the patients in Objective: To present the first experience with the new da Vinci Single-Site
the liver suspension group. System and assess feasibility, advantages and limitations.
Conclusion: We present our simple liver suspension technique to minimize Methods: In February 2011, a single-site robotic surgery program was initiated
hepatic trauma from liver retraction during radical robotic and laparoscopic in our center. Cholecystectomy was selected as the pilot procedure. All
gastrectomies. Compared to the liver puncture method, our novel liver procedures were completed using the da Vinci Si robotic surgical system. Novel
suspension method resulted in less hepatic trauma. specialized flexible 5mm analogues of the standard instrument set was used. All
instruments were introduced through Intuitive’s 2cm single site robotic port. A
P070: DEEP FLEXION KINEMATICS WITH ROBOTIC MODULAR KNEE bed side assistant contributed to gallbladder traction.
ARTHROPLASTY Toshifumi Watanabe, MD, Scott A Banks, PhD, Stefan Results: Perioperative data were obtained for all patients including demographic
Kreuzer, MD, Kevin J Leffers, MD, Takeshi Muneta, MD PhD, Michael A data, operative indications, operative records, length of stay, complications, and
Conditt, PhD, Jennifer A Jones, BS University of Florida, Gainesville, Florida; pathologic analysis.
Memorial Bone and Joint Research Foundation, Houston, Texas; Tokyo Medical
and Dental University, Tokyo, Japan; MAKO Surgical Corporation, Fort Conclusions: Robotic single site cholecystectomy is feasible and safe. Technology
Lauderdale, Florida offers surgeons numerous potential benefits, including: superior identification of
biliary anatomy, meticulous dissection of Calot’s triangle, improved gallbladder
Introduction In knee arthroplasty, several studies have shown that sparing soft retraction and exposure, better ergonomics with no instrument crowding
tissue, particularly the ACL, will allow a patient to retain kinematic function and stable visualization of the field. Cost remains a disadvantage for adoption
that more closely relates to normal function versus those with cruciate of more single-site supporters. Additional platform and instrumentation
substituting implants. Multi-compartment modular knee replacement has a development will likely simplify robotic single site procedures further as
long history of favorable outcomes. In 1976, Laskin reported good pain relief experience grows.
and acceptable clinical results after bi-unicondylar knee replacement with a
follow-up of two years. In 1995, Argenson et al. reported on a series of 183 P072: LESSONS FROM AVIATION: CHECKLISTING IN FRONT OF THE
patients who received patellofemoral replacements (PFA) and 104 of which ROBOTIC SURGICAL ’COCKPIT’. SURGICAL TECHNIQUE CHECKLISTS
simultaneously underwent medial unicompartmental replacement (UKA). FOR INTRAOPERATIVE USE WITH THE DAVINCI SYSTEM. Savas C
84% of patients received satisfactory results although the subset of patients Hiridis, MD MSc, Konstantinos M Konstantinidis, MD PhD FACS, Petros
who received PFA-UKA replacements were not distinguished form the overall C Hiridis, MD, Fotis Antonakopoulos, MD, Dimitris Mousiolis, MD,
series of patients. While modular knee replacement has had good clinical Kouloufakou Kalliopi, MD ATHENS MEDICAL CENTER
results, difficulties exist in achieving precise implantation. Robotic-arm
assisted orthopedic surgery has the potential to achieve levels of accuracy, Introduction: Modern surgical practice demands the use of evidence-based
precision, and safety not possible with conventional techniques. With the use guidelines. A Surgical Safety Checklist from WHO has already been
of robotic-arm guidance Lonner examined a series of 12 consecutive modular adopted from more than 200 surgical societies and 20 ministries of health
bicompartmental arthroplasties using discreet components and observed internationally. Laparoscopic and robotic procedures depend on hundreds of
a mean post-operative Rom at 126 degrees of flexion with statistically parameters that need to be checked for their safe and efficient completion.
significant improvements in WOMAC and KSS scores at short-term follow- Methods: Using the TILE-PRO system of da Vinci Si we propose a set of
up. This study analyzed the kinematics of a series of patients that underwent Checklists to use before, and after the procedures. An electronic database of
robotic-arm guided knee arthroplasty with a modular implant system where surgical technique checklists was created based on our standardized techniques
both cruciate ligaments were preserved in a uni- or multi-compartment knee and existing literature. The checklist was read by the surgeon and completed
arthroplasty. No prior study has analyzed kinematics with modular knee by the assistants before and after the operations.Results: The process promoted
arthroplasty. safety and facilitated standardization of surgical techniques among team
Materials & Methods We analyzed six osteoarthritic knees that underwent members. It also served educational purposes.
robotic-arm guided knee arthroplasty with modular implant components. All Conclusions: Use of surgical checklists can minimize human error and facilitate
surgeries were performed by one surgeon (SWK). The age of the patients at standardization of the techniques. The robotic console offers an excellent
time of surgery was 60 ± 10 years. The average patient follow-up was 12 ± 3 platform for exchange of digital information during surgery. Our small
months. Patients were studied fluoroscopically while they performed daily living experience shows that checklists are going to play a central role in the surgical
activities (lunge and kneel). Three dimensional kinematics were assessed from practice of the next decades.
single plane fluoroscopic images using a proven technique from Banks, et al.
Results The average maximum flexion angles observed during kneeling was 127 P073: ROBOTIC TRAINING : LESSONS TO BE LEARNED FROM THE
± 7 degrees and 120 ± 10 during lunging. The mean axial rotation observed AERONAUTIC PRACTICE ? J. Hubert, MD, G Herrmann, M Perez, MD,
during kneeling was 27 ± 6 degrees and 28 ± 7 degrees during lunging. Mean C Perrenot, C Waked, MD, N Hubert, MD, N Tran, MD 1) Department of
rollback observed during kneeling was 19 ± 9mm and 17 ± 7mm during Urology, CHU Nancy-Brabois 54511 VANDŒUVRE les NANCY, FRANCE.
lunging. 2) School of surgery :UHP-Nancy1, 54500 VANDŒUVRE les NANCY,
FRANCE. 3) Air France company, Paris
Discussion: The observed deep flexion kinematics related more closely to normal
knee kinematics than previously published results for TKA. Although this study Introduction: Robotic surgery is developing exponentially, this raising the
included a small number of patients, it was observed that robotic-arm assisted question of surgeons’ training in this new practice. This training requires a
modular knee arthroplasty was indicated to replicate normal knee kinematics in learning course and assessment that could be based on those used by pilots when
deep flexion. Further research with a larger subset of patients would strengthen qualifying on a new aircraft type.
these findings. Material & Methods: Learning and skills on a new aircraft require training that
is highly structured, product of decades of experience in a constant search for

54 6 TH ANNUAL MIRA CONGRESS May 11-13, 2011


quality, with an official endorsement by government authorities. It must lead to standard laparoscopic approach. The use of Robot during pregnancy was
a success rate close to 100% given the level of candidates participating in this reported earlier and showed to be as safe as laparoscopy. The use of robotic
training and given economic issues. surgery in ovarian cancer during pregnancy has not been reported before.
To our knowledge this is the first case of Robotic assisted surgical staging for
Results: This type of training uses CAI (computer assisted instruction), lectures,
presumed early ovarian cancer.
fixed simulator training (systems and equipment) and then a flight simulator.
Flights as copilot are allowed after successful completion of the course. These Case: 29 years old woman underwent laparotomy for a right ovarian cystectomy,
steps do not exist in surgical training, which remains with a halstedian model, for presumed endometrioma, the final pathology showed endometrioid
although many similarities exist. Training in robotic surgery could include steps adenocarcinoma Grade I of the ovary in a background of endometriosis. The
like using a simulator that appeared recently on the market and the practicing patient was referred to a tertiary center and got pregnant in the mean while and
surgery on the animal (dry and wetlab). decided to keep the pregnancy. The staging was achieved using Da Vichi robotic
assisted surgery in the mid trimester.
Conclusion: Training in robotic surgery and assessment of surgeons is still in its
infancy when compared to the training of airline pilots. Many parallels can be Conclusion: The use of Robotic surgery during pregnancy is feasible at the mid-
drawn and the robotic surgeons’ training could be more effective if inspired by trimester; uterine manipulation can be added by the use of fan retractor with no
the established protocols in aviation. compromise to complete procedure.

P074: ROBOTIC-ASSISTED GYNECOLOGIC/ONCOLOGIC SURGERY: P076: SURGICAL OUTCOMES WITH ROBOTICS AND MORBIDLY
EXPERIENCE OF EARLY CASES IN A SAUDI ARABIAN TERTIARY CARE OBESE WOMEN Pamela J Stone, MD, Mohamed Ismaeil, MD, Alexander
FACILITY Ismail A Al-Badawi, MD, Murad Z Al-Aker, MD, Ibtihal Bukhari, Burnett, MD University of Arkansas for Medical Sciences
MD, Sarfraz Ahmad, PhD, Jamal Alsubhi, MD King Faisal Specialist Hospital Introduction: Minimally invasive techniques are increasing in the United States
& Research Center, Riyadh 11211, Saudi Arabia; 2Florida Hospital Cancer at the same time as obesity rates are trending upwards. Previous reports have
Institute, Orlando, FL 32804, USA commented on the effect of BMI on minimally invasive techniques however
Objective: To report our early experience of case-mix series of robotic-assisted there is limited information regarding robotic surgery in the morbidly obese
gynecologic/oncologic surgery in Arabian population from a tertiary care facility, gynecologic patient. Laparoscopic surgery has been accepted as an appropriate
and to discuss the emergence/growth of robotic surgery in the Middle-East. technique to apply to uterine malignancies as demonstrated with the prospective
LAP study. Robotic surgery may offer an additional tool for these patients in the
Methods: From December 2005 to September 2010, 51 consecutive patients
standard treatment of endometrial cancer.
[benign with complex pathology (BN, n=29) and 22 cases with various
malignancies; i.e., cervical cancer (CC, n=1), endometrial cancer (EC, n=11), Methods: Retrospective evaluation of consecutive cases who underwent robotic
ovarian cancer (OC, n=3), and other cancers including recurrent borderline/ surgery with a BMI ≥ 40 (kg/m2). Foley and uterine manipulation was used
bone metastases (OTH, n=7), underwent robotic-assisted procedures for the for all cases. Times were extrapolated from medical record for operating room
diagnosis, treatment, and management of gynecologic/oncologic diseases at a and console time. Surgeons performed nodes based on grade and depth of
single institution using da Vinci® Robotic Surgical System (Intuitive Surgical myometrial invasion from operating room inspection.
System, Inc., Sunnyvale, CA). Data were analyzed for demographics, clinico- Results: Over a 2-year time period, 54 morbidly obese women underwent
pathologic and peri/post-operative factors, including operative time (OT), robotic surgery. The average age was 51 years, and the average BMI was 53
estimated blood loss (EBL), hospital length-of-stay (LOS), and complications (40-98). The average blood loss was 171ml and the average hospital stay was
using an intent-to-treat analysis. 1.2 days. There were no conversions due to complications however one case
Results: Despite continuous growth in the cases performed each year, the required a mini-laparotomy to remove an enlarged uterus (696gm), and
establishment of robotic surgery program at our institution has been rather one case was abandoned due to airway disease exacerbation at anesthesia
challenging due to patient acceptance, public awareness, and administrative induction. 42 cases were for uterine cancer, 76.2% grade 1 and 23.8% grade
resistance. Mean age of all case-mix was 43±15 years (distribution: BN 39±14, 2/3. 9 cases were for endometrial hyperplasia, 2 for cervical dysplasia and 1
EC 61±6, OC 36±15, CC 50, and OTH 41±12 years). Body mass index (BMI) for adjuvant treatment. In 46.2%, hysterectomy with BS&O was performed;
for all case-mix was 30.3±6.9 kg/m2 (distribution: BN 29.7±6.2, EC 34.0±3.6, additionally 33.3% and 13% had a pelvic and aortic node dissection. One
OC 20.0±1.7, CC 48, and OTH 30.2±6.2 kg/m2). Histology of most of the EC radical hysterectomy was performed. The average uterine weight was 192 gm.
cases was endometriod adenocarcinoma. The skin-to-skin OT was: all case-mix There were 11 complications with 2 patients have 2 complications--2 blood
95±43, BN 77±26, EC 156±30, OC 80±35, CC 150, and OTH 79±23 min. transfusion, 3 infections, 3 respiratory problems, 1 incarcerated hernia, 1
Mean EBL were: case-mix 126, BN 129, EC 177, OC 67, CC 50, and OTH 71 cuff hematoma and 1 vaginal cuff bleeding. The average peak airway pressure
min. Two robotic cases (3.9%) were converted to laparotomy (one each in EC was 40.6, average tidal volume 471ml, FIO2 58, ETCO2 36 and an average
and BN groups). Mean LOS was 2-days (although most patients were clinically OR time 272 min. Of the 32 grade 1 uterine cancers, 53% had a pelvic node
ready for discharge on day-1, but stayed longer due to various social reasons). Four dissection and 9% had an aortic node dissection. 10 patients had grade 2/3
cases (7.8%) experienced complications [two in EC (post-op bleeding, post-op uterine cancers and 70% underwent pelvic node dissection and 40% had
supraventricular tachycardia) and two in BN (wound infection, right common iliac aortic node dissection. The average pelvic and aortic node counts were 12
artery laceration)]. Only 5/22 (22.7%) cancer cases required adjuvant therapy and 4 respectively. The node count increased as surgeon experience increased
[EC 2 (radiation), EC 1 (chemotherapy), EC 1 (chemotherapy/radiation) and CC 1 (>10 cases).
(chemotherapy)]. No peri/post-op related mortality was encountered. Conclusions: As obesity rates increase, gynecologic oncology surgeons are faced
Conclusions: These data suggest that robotic-assisted gynecologic/oncologic with performing surgery in morbidly obese patients. Our data demonstrates
procedures are feasible and satisfactory to our Arabian patient population, and few complications, a high proportion of staged patients, and feasibility of
comparable to the existing literature for Caucasian counterparts in the Western the surgical approach. The use of robotic technology affords this benefit
world. We believe this is the first (and perhaps largest) case-mix series being applied to our morbidly obese patients while facilitating the technical
reported on the early experience of robotic-assisted surgery for gynecologic/ difficulties facing the surgeon and anesthesiologist. With increasing time
oncologic cases from Middle-East, and that this approach is gaining acceptance and surgeon experience, nodal dissection could be accomplished adequately
in our socio-culturally unique part of the world. without jeopardizing the care of the patient and with acceptable surgical
times. Robotic assistance provides the surgeon with the tool to overcome the
P075: ROBOTIC ASSISTED SURGICAL STAGING FOR OVARIAN challenges that an extremely obese patient presents. Further feasibility and
CANCER IN A PREGNANT WOMAN Ismail A Al-Badawi, MD, Murad Z Al- outcome studies are needed in this group of patients who are representing a
Aker, MD, Wesam Kurdi, MD, Jamal Alsubhi King Faisal Specialist Hospital & greater portion of our patients.
Research Center, Riyadh 11211, Saudi Arabia
Abstract Background: The Robotic assisted surgery is becoming popular among
surgeons as it allows more control with comparable benefits and risks to the

www.mirasurgery.org 55
Poster Abstracts
P077: ROBOTIC EXTRAPERITONEAL ENDOSCOPIC AORTIC P079: VAGINAL CUFF DEHISCENCE AFTER ROBOTICALLY ASSISTED
LYMPHADENECTOMY: AN EXPERIMENTAL PIG MODEL Dominique PROCEDURES REQUIRING A COLPOTOMY Mario M Leitao, MD, Ginger
Lanvin, MD, Monique Bertrand, MD CSTAR (Canadian Surgical Technologies J Gardner, MD, Gabriel Briscoe, Elizabeth Jewell, MD, Nadeem R Abu-
& Advanced Robotics) Lawson Health Research Institute, London, Ontario, Rustum, MD, Carol L Brown, MD, Dennis S Chi, MD, Yukio Sonoda, MD,
Canada Douglas A Levine, MD, Richard R Barakat, MD Memorial Sloan-Kettering
Cancer Center
Objective of the study: Robotic extraperitoneal endoscopic aortic
lymphadenectomy (REEAL) is an advanced surgical procedure in gynecology Objective: To determine the rate of postoperative vaginal cuff dehiscence in
oncology. Lymph node involvement is a crucial prognostic factor in most of the patients undergoing robotically assisted procedures that require colpotomy.
pelvic cancer. REEAL needs to be evaluated in comparison with laparoscopic Methods: We identified all cases undergoing a robotically assisted procedure for
approach. An experimental model is useful for an accurate evaluation of a various indications from 5/15/07 to 9/29/10. From this cohort, we identified
new surgical procedure. An animal model is an important part of the surgical patients who required a colpotomy for procedure completion and were not
training of the residents and fellows in gynecology oncology . There is no converted to laparotomy. Clinical data were extracted from the electronic
experimental animal model for REEAL. The goal of this study is to show the medical record. Various additional procedures were performed in many cases,
feasibility of REEAL in a porcine model. but we did not include these other procedures in our analyses. It is standard
Methods & Procedures: Five pigs had a general anesthesia in this study according practice at our institution to close the vagina primarily using a running 0-vicryl
the guidelines of the animal care of the laboratories. Two surgeons were suture as would be done via laparotomy and encompassing at least 1 cm of
enrolled. The first one is gynecology oncologist trained in advanced laparoscopic vaginal mucosa. No other vaginal closure devices or disposables are used.
and robotic assisted gynecologic oncology surgery. He is able to perform an Results: We identified 484 robotically assisted cases that required a colpotomy as part
extraperitoneal endoscopic aortic lymphadenectomy by laparoscopy. The of their procedure and were not converted to laparotomy. The median age was 58
other one is a gynecology oncologist trained in laparotomy only. A REEAL was years (range, 27-89). The median BMI was 27.6 kg/m2 (range, 16.2-66 kg/m2).
performed using a three-arm Da Vinci robot. None of the cases involved a vaginal approach. A simple hysterectomy was performed
Results: The first two pigs were used in order to create the appropriate model for in 441 cases (91%), radical hysterectomy in 30 (6%), simple trachelectomy in 4
the trocar’s placement and robot’s docking. Three pigs had a REEAL. (<1%), radical trachelectomy in 8 (2%), and radical parametrectomy in 1 (<1%)
case. The median time to close the vaginal cuff was 19 minutes (range, 2-108).
Conclusion: REEAL is feasible in a pig model. This model can be used for
The indication for surgery was malignancy in 355 (73%) of 484 cases. Vaginal cuff
evaluation of the learning curve, safety and accuracy of the REEAL. It remains
dehiscence was diagnosed in 4 cases (0.8%). These 4 cases were all performed in the
an excellent model for the training of the resident and fellow before their first
setting of malignancy, and the BMI was <30 kg/m2. All 4 dehiscences were small
clinical surgical experience and could decrease the learning curve.
and partial, and none had bowel evisceration. Spontaneous dehiscence occurred in
P078: POSTOPERATIVE PAIN MEDICATION REQUIREMENTS 3 (75%) of the 4 cases and were allowed to close without surgical intervention. One
IN PATIENTS UNDERGOING ROBOTICALLY ASSISTED AND of the 4 dehiscences occurred after intercourse prior to 6 weeks from surgery and
STANDARD LAPAROSCOPIC PROCEDURES FOR NEWLY DIAGNOSED required a single suture under anesthesia.
ENDOMETRIAL CANCER Mario M Leitao, MD, Ginger J Gardner, MD, Conclusions: Vaginal cuff dehiscence is a rare event (<1%) after robotically
Gabriel Briscoe, Priyal Dholakiya, Kevin Santos, Elizabeth Jewell, MD, Nadeem assisted procedures and can be avoided if proper surgical techniques are used.
R Abu-Rustum, MD, Yukio Sonoda, MD, Richard R Barakat, MD, Vivek The majority are partial, and can be managed conservatively.
Malhotra, MD Memorial Sloan-Kettering Cancer Center
P080: INTEGRATION AND TRAINING OF ROBOTICALLY-ASSISTED
Objective: To compare postoperative pain medication use in patients undergoing
SURGERY IN A GYNECOLOGIC ONCOLOGY FELLOWSHIP PROGRAM
robotically assisted (RBT) and standard laparoscopic (LSC) procedures for
Mario M Leitao, MD, Ginger J Gardner, MD, Gabriel Briscoe, Kevin Santos,
newly diagnosed endometrial cancer.
Elizabeth Jewell, MD, Carol L Brown, MD, Dennis S Chi, MD, Richard R
Methods: All cases with a preoperative endometrial cancer diagnosis scheduled Barakat Memorial Sloan-Kettering Cancer Center
for RBT or LSC from 5/1/07-6/19/10 were identified. A standardized
Objective: To assess the feasibility and outcomes of integrating robotically-assisted
postoperative pathway includes routinely offering all patients IV patient-
surgery in a gynecologic oncology fellowship program.
controlled analgesia (PCA). Various IV PCA data points were retrospectively
abstracted from the electronic medical record for patients who did not require Methods: We identified all cases planned for a robotically-assisted procedure from
conversion to laparotomy and had an IV PCA started postoperatively. All 5/15/07 to 9/28/10. Various procedures for benign and malignant gynecologic
medication doses were converted to equivalent fentanyl doses using institutional indications were performed during this time period. Time points were prospectively
conversion guidelines. The total fentanyl dose was calculated. The total fentanyl captured intraoperatively as part of an ongoing quality assessment program. All
dose was then divided over the total number of hours the patient had access to cases were performed with a gynecologic, surgical, or urologic oncology fellow.
the PCA to calculate the hourly fentanyl dose (HFD). Fellow time spent on the surgeon console performing some or all of the procedure
was captured intraoperatively for cases that were not converted to laparotomy.
Results: We identified 239 RBT and 244 LSC cases that were not converted
Total operating room time (ORT) was determined from patient arrival to exit in
to laparotomy. Baseline patient characteristics were similar. An IV PCA was
the operating room. Total operating time (OT) was determined from skin incision
used in 206 RBTs (86%) and 217 LSCs (89%) (P=0.2). Ketorolac was given
to completion of skin closure. Time periods were compared as follows: first year
concurrently in 77% of cases in both groups (P=0.9). Fentanyl was used in
(Y1)=2007/2008, second year (Y2)=2009, third year (Y3)=2010. Complications
196/206 RBTs (95%) and 195/217 LSCs (90%) (P=0.02). A basal infusion was
were assessed within 30 days of surgery. Appropriate statistical tests were used.
used in 3 (1.5%) and 21 (10%), respectively (P<0.001). The median number of
patient attempts was 14 (range, 0-372) for RBT and 21 (range, 0-349) for LSC Results: There were 775 cases planned for a robotically-assisted procedure during
(P<0.001). The median number of hours with access to a PCA was 14.9 (range, our study period; 162 (Y1), 331 (Y2), and 282 (Y3). The median age, median
0-51) for RBT compared to 16.8 (range, 7-180) for LSC (P<0.001). The median BMI, and malignancy as an indication for surgery was similar for all 3 time periods
number of additional medication boluses needed was 1 (range, 1-5) for RBT and (P=NS). Conversion to laparotomy occurred in 23/162 (14%) Y1 cases, 29/331
2 (range, 1-6) for LSC (P=0.03). The total fentanyl dose received for RBT cases (9%) Y2 cases, and 18/282 (6%) Y3 cases (P=0.02). In cases not converted to
was 242.5 ucg (range, 0-2705 ucg) compared to 367.5 ucg (range, 0-2625 ucg) laparotomy, fellows sat at the surgeon console in 17/139 (12%) Y1 cases, 151/302
for LSC (P<0.001). The median HFD was 16.7 ucg (range, 0-51 ucg) for RBT (50%) Y2 cases, and 183/264 (69%) Y3 cases (P<0.001). The median ORT was
compared to 22.7 ucg (range, 0-132.4 ucg) for LSC (P=0.01). Simultaneous 298 minutes (range, 116-670) for Y1, 249 minutes (range, 104-659) for Y2, and
multiple regression analysis further demonstrated that RBT was independently 225 minutes (range, 79-584) for Y3 (P<0.001). The median OT was 218 minutes
associated with a lower total fentanyl dose compared to LSC (P=0.04). (range, 58-533) for Y1, 169 minutes (range, 34-562) for Y2, and 148 minutes
(range, 39-496) for Y3 (P<0.001). In the cases not converted to laparotomy,
Conclusions: The use of the robotic platform is independently associated with
intraoperative and postoperative complications occurred in 25/139 (18%) Y1
significantly lower postoperative pain medication requirements compared to
cases, 27/302 (9%) Y2 cases, and 15/264 (6%) Y3 cases (P<0.001).
standard laparoscopy.
56 6 TH ANNUAL MIRA CONGRESS May 11-13, 2011
Conclusions: Robotically-assisted surgery can be safely and efficiently integrated Objectives: To demonstrate the safety, utility and feasibility of robot-assisted
into a gynecologic oncology fellowship program. Despite significant increased laparoscopic treatment of bladder endometriosis.
fellow participation on the surgeon console, there were continued overall Materials & Methods: Two women, aging 30-33, with a 4-5 cm bladder mass on
improvements in ORT, OT, rate of conversion, and complication rates. pelvic ultrasonography and history of infertility/pelvic pain were enrolled.
Cystoscopy biopsy in one case revealed endometriosis. After hormonal medical
P081: COLPOTERES SUSPENSION PROCEDURE John S Missanelli, DO
therapy was performed excision of endometriosis bladder nodule with partial
Grossmont Obstetrics and Gynecology
cystectomy with robotic assistance (da Vinci) in 2010.
A unique procedure to restore pelvic floor prolapse is embodied in the technique
Results: Robotic-assisted with da Vinci system partial cystectomy with
of the colpoteres/cervicoteres suspension procedure. With robotic assisted
concomitant excision of endometrial nodules from peritoneum was performed
laparoscopy, the round ligaments are attached to the angles of either the cervical
in a mean time of 150 min. The blood lost was 50cc. Patients had an uneventful
stump or the vaginal vault, at the time of robotic total or supracervical hysterectomy,
postoperative course and hospital stay. Follow-up imaging revealed no bladder
or as a primary procedure if hysterectomy has been previously done. The suspension
extravasation or fistula formation.
is then reinforced with a Prolene mesh that has been"sandwiched" between coverings
of Bovine integument, and covered with posterior parietal peritoneum. Pelvic Conclusions: Endometriosis is the presence of endometrial glands and stroma
Organ Prolapse Quotient Scores are assigned to the patient before, immedately post outside of the uterine cavity. Robotic-assisted laparoscopic partial cystectomy for
operatively and at six weeks and six months. In a series of twenty-five cases to date, endometriosis can be safely performed and provide advantages in the management
there has been restoration of the POP-Q to 0 or 1 with no recurrance of prolapse. of women with severe endometriosis secondary to 3-dimensional visualization,
The MSN Procedure(Missanelli, Steele, Naponic) is offered as competitive and a decreasing surgeon’s fatigue and hand tremors and improving surgical precision.
proven alternative to robotic assisted laparoscopic sacrocolpopexy.
P084: ROBOTIC ASSISTED LAPAROSCOPIC ABDOMINAL CERCLAGE: A
P082: INTRODUCTION OF ROBOTIC TECHNOLOGY FOR NOVEL APPROACH Donna Brown, MD, Frank Craparo, MD, Mark Shahin,
HYSTERECTOMY: ANALYSIS OF FEASIBILITY AND COMPLICATION MD, Larry Barmat, MD Abington Memorial Hospital, Abington, PA
RATES DURING THE FIRST 4 YEARS OF USE Sidonia-Maria Saceanu, Abdominal cerclage has been shown to be of benefit in the outcomes of patients
Resident Doctor, Nicola Pluchino, Dr, Letizia Freschi, Dr, Vito Cela, who fulfill the criteria for placement, ie failed cervical cerclage or lack sufficient
Dr, Marcela Goga, Dr, Lavinia Dobrescu, Dr, Alexandru Goganau, Dr, length of cervix inside the vagina. However with traditional abdominal cerclage,
Andrea Genazzani, Professor Department of Reproductive Medicine and comes the risk and complications associate with laparotomy. The patients had
Child Development Division of Gynecology and Obstetrics University of to spend days in the hospital and had weeks of recovery. In addition the patient
Pisa,Italy,Department of Gynecology and Obstetrics II, University Hospital had to then undergo a second laparatomy for delivery. As technology progressed,
Craiova,Romania gynecologists became more adept with laparoscopy and more recently with robotic
Objective: To determine the prevalence, indications, success rate and surgery. Surgeries previously requiring lengthy hospital stays could be done with
complications in performing hysterectomy (simple and radical) using robotic small incisions and require little to no hospital stay. With advent of laparoscopy
technology. and increasing number of physicians skilled in advanced laparoscopic skills, the
idea of performing an abdominal cerclage laparoscopically became feasible.
Study Design: Retrospective study of 59 hysterectomies performed from
November 2007 through December 2010 (4 years) at Cisanello Hospital - Ob/ The patient is a 28 year old G4P0130 with a significant past obstetrical history
Gyn - University of Pisa, Pisa. Data included diagnosis, patient characteristics, of two prior first trimester losses and two second trimester losses, the latter of
surgical procedure (duration, type, blood lost), and hospitalization days and which was despite the placement of a transvaginal McDonald cervical cerclage.
complications rate. After evaluation by the Maternal Fetal Medicine group she was determined to
be a candidate for abdominal cerclage. The patient was counseled that in the
Patients: 59 women (35-75 years) were analyzed. All patients received a robotic-
literature there are several case reports of abdominal cerclage being performed
assisted laparoscopic hysterectomy (simple or radical) from September 2007 to
laparoscopically and with the use of the da Vinci robot. At this institution, one
December 2010 in Cisanello Hospital - Ob/Gyn - University of Pisa, Pisa.
prior robotic assisted abdominal cerclage had been successfully placed. The patient
Intervention: Robotic-assisted laparoscopic hysterectomy using Da-Vinci System decided on a minimally invasive approach.
Results: In 2007 were performed 2 hysterectomies, in 2008 the number The trochars were placed as in typical for pelvic surgery with the aid of the da
of procedure increased to 8 hysterectomyes; in 2009 we performed 19 Vinci robot. A uterine manipulator was also used. Using blunt and sharp dissection
hysterectomies and in 2010, n°30 hysterectomies. The percentage increased of the bladder flap was created. In the prior abdominal cerclage, the Maryland was
30-65% hysterectomies at year. We performed 19 hysterectomies for cervical used to pierce a hole in the broad ligament in an anterior to posterior fashion.
cancer, 22 hysterectomies for endometrial cancer and 18 hysterectomies for Due to the patient’s anatomy, this technique was not feasible. The bladder flap
uterus fibromatosis. Blood loss during surgery was 50-175 cc without significant was then extended sharply to the level of the cervicovaginal junction and the
changes in hemoglobin value. Hospitalization period was 2 days. Patients had an width extended so that the pulsation of the uterine arteries could be visualized.
uneventful postoperative course. A segment of 2-0 vicryl was attached to the mersilene tape. The needle was
Conclusions: Route of hysterectomy changed significantly after the introduction of straightened and the combination was placed on the inside of the uterine arteries.
robotic technology. Open hysterectomy was associated with significantly higher The excess was cut off and the mersilene tape tied on the posterior aspect of the
complication rates than robotic hysterectomies, more blood lost, more days of uterus. Excellent hemostasis was noted with minimal blood loss. The patient was
hospidalization. Robotic hysterectomy is a recommended intervention in variety able to go home the same day.
of gynecologic conditions including: abnormal excessive bleeding, fibroids, The patient subsequently became pregnant. Her pregnancy was complicated by
endometrial and cervical cancer. The daVinci surgical system provides surgeons gestational diabetes. She delivered a viable male infant in the breech presentation
with enhanced true 3-D vision, ergonomic comfort of surgical manipulation and at a scheduled 39 week cesarean section. At the time of delivery, no adhesions
unprecedented precision of tissue handling. In this specific area of hysterectomy were noted and the cerclage was found to be intact in the correct position. The
Da Vinci System, decreased blood loss, increased recovery time, greatly reduced cerclage was left in place for future pregnancies.
post-operative pain, quicker return to daily activities, improved cosmesis.
This case demonstrates that an abdominal cerclage can be successfully placed
P083: ROBOTIC SURGICAL REMOVAL OF BLADDER ENDOMETRIOSIS using the da Vinci robotic system. Case reports similar to this are increasing in the
-THE NEW GOLD STANDARD? Sidonia-Maria Saceanu, Dr, Nicola literature but still more information is needed to determine the ideal technique
Pluchino, Dr, Letizia Freschi, Dr, Alexandru Handabureac, Dr, Ayed Kamal, and long term outcomes.
Dr, Alexandru Goganau, Dr, Vito Cela, Dr, Andrea Genazzani, Professor
P085: ROBOT-ASSISTED VERSUS OPEN RADICAL HYSTERECTOMY: A
Department of Reproductive Medicine and Child Development Division of
COMPARISON OF ONE SURGEON’S OUTCOME. Bilal M Sert, MD, Vera
Gynecology and Obstetrics University of Pisa,Italy,Department of Gynecology
Abeler, MD PhD The Norwegian Radium Hospital
and Obstetrics II, University Hospital Craiova,Romania

www.mirasurgery.org 57
Poster Abstracts
Objective: To compare internally one surgeon´s abdominal radical hysterectomy Methods: Retrospective chart review of 77 cases of endometrial cancer who
(ARH) and robot-assisted laparoscopic radical hysterectomy (RALRH) results. underwent robotically assisted staging between September 2006 and September
2010. Data abstracted included patient demographics, operative notes, and
Methods: As an internal control, we selected 26 ARH cases performed by the
pathology reports. Data were analyzed using chi-square test for the presence of an
same surgeon (BMS) and compared his 43 RALRH cases. We compared the
association between the use of a uterine manipulator and LVI. Fisher exact test was
clinical characteristics, perioperative results and mean 3 years outcomes.
used for small numbers. Logistic regression model was used to confirm results.
Results: The study and control groups had similar characteristics ( age, body mass
Results: Seventy seven cases were included in the study. All had robotically
index, stage). The RALRH group had a statistically significant advantage for
assisted total laparoscopic hysterectomy bilateral salpingoopherectomy and
estimated blood loss (83 ml versus 595 ml. p<0.0001) and hospital stay (4 days
retroperitoneal lymph node dissection for endometrial cancer. 18 cases were
versus 9 days p<0.001). At the mean 3 years follow-up the recurrence rate is
completed with the use of a uterine manipulator (Group A). 59 cases were
higher in RALRH group while only one death occurred in each group.
completed with the use of a sponge stick to delineate the vaginal fornix (Group
Conclusions: We present the results of RALRH and ARH performed by one B). Seven cases in Group A had LVI compared to 5 cases in Group B (P=0.298).
surgeon. With only a 43 cases experience, RALRH offers the benefits of Lymph node metastasis was found in 1cases in Group A compared to 5 cases in
minimally invasive surgery and does not compromise both clinical and pathologic Group B (P=1.00). Positive washing was found in 1cases in Group A compared
outcomes. The recurrence rate is 11.1% after the mean 3 years follow-up. to 6 cases in Group B (P=1.00). In a logistic regression model, none of the above
variables was independently associated with the use of a manipulator.
P086: MORBID OBESITY OUTCOMES IN ROBOTIC GYNECOLOGIC
SURGERY Taryn Gallo, MD, Masoud Azodi, MD Yale New Haven Health / Conclusion: The use of a uterine manipulator in robotic assisted surgical staging
Bridgeport Hospital for endometrial cancer seems not to be associated with an increased incidence of
lymphatic vascular spread of malignant cells.
Study Objective: To assess perioperative outcomes in morbidly obese patients
undergoing robotic hysterectomy. P089: SINGLE PORT HYSTERECTOMY: CONVERTING FROM SINGLE
Methods: A retrospective cohort study was performed for patients who PORT LAPAROSCOPY TO SINGLE PORT ROBOTIC: THE GREEK
underwent robotic hysterectomy from September 2006 to June 2010 for EXPERIENCE OF INTRODUCING INNOVATIVE SURGERY IN A
both benign and malignant indications. Patient demographics, intraoperative FINANCIAL CRISIS ENVIRONMENT Stefanos Chandakas, MD MBA PhD,
outcomes, rates of complication, readmission, and reoperation were compared John Erian, FRCOG Iaso Group of Hospitals, Athens, Greece and Attikon
for those patients having a body mass index (BMI) of 35 kg/m2 or greater with University Hospital, Athens, Greece
those whose BMI was less than 35 kg/m2. Minimally invasive surgery has influenced the techniques used in gynaecology,
Results: Of 380 patients who met inclusion criteria, 150 (39%) women were with an overall minimisation of complications and increased patient satisfaction.
morbidly obese with a BMI of 35 kg/m2 or greater. In the morbidly obese The study objective is to demonstrate the safety and feasibility of Single Port
group, the mean BMI was 42.6 kg/m2 vs. 27.2 kg/m2 in the comparison (SP) Total Laparoscopic Hysterectomy and ther issues that need to be addressed
group. There were no significant differences between the groups in terms before converting to Single Port Robotic Hysterectomy
of estimated blood loss, uterine weight or length of hospital stay (138 vs. Methods & Procedures: Retrospective, descriptive, non randomized study
123 mL, P = .16; 210 vs. 224 gms, P = .54; 1.3 vs. 1.4 days, P = .31,
Setting: Iaso Hospital and Attikon University Hospital, Athens, Greece
respectively). There were no significant differences in complication,
readmission, and reoperation rates between the two groups. There was one Patients: 22 patients underwent SP Total Laparoscopic Hysterectomy between
conversion in the morbidly obese group. October 2008 and January 2011. Indications included 88% Dysmenorrhoea and
12% Large Fibroids Uteri
Conclusions: Robotic hysterectomy can be performed safely in morbidly obese
patients, with surgical outcomes and complication rates similar to those for non- Main Results: Duration of operation and of hospital stay, safety (morbidity and
morbidly obese patients. mortality), and patient satisfaction were assessed .Estimated blood loss was 110
ml (range 165-300 ml) Intraoperative complications: 0% vascular injuries and
P087: INCIDENCE OF VAGINAL CUFF DEHISCENCE WITH ROBOTIC 0% nerve or ureter injuries. Early postoperative morbidity included no major
HYSTERECTOMY: AN ANALYSIS OF 500 CASES Taryn Gallo, MD, Masoud complications, 0% bladder infection and dysfunction and 0.22% of incision
Azodi, MD Yale New Haven Health / Bridgeport Hospital infection. 51% of patients were discharged to home the same day with an average
Study Objective: To assess the rate of vaginal cuff dehiscence in patients length of stay for these patients of 14 hours .The compared cost with traditional
undergoing robotic-assisted laparoscopic hysterectomy (RALH). laparoscopic hysterectomy was reduced by 22%, mainly due to the use of
reusable instruments and just one single use Single Port Special Trocar.
Methods: A retrospective analysis of 500 patients who underwent robotic
hysterectomy from September 2006 to August 2010 for both benign and Conclusions: Single port Total Laparoscopic Hysterectomy seems to be a safe
malignant indications. and more cost effective alternative to traditional Laparoscopy. Our unit will
introduce the Robotic approach once the DaVinci Robotic system will get FDA
Results: There were 2 cases (0.4%) of vaginal cuff dehiscence. Intercourse was licensing for Single Port Surgery. Surgical time, safety and feasibility, additional
the triggering event for the first case, which occurred 85 days after RALH. The costs, complexity and combination of procedures will be addressed before
second case occurred 30 days after RALH with the triggering event of straining moving to the new robotic approach.
during defecation. Both cases were promptly repaired vaginally with one
requiring laparoscopic assistance. P090: ENDOMETRIAL CANCER AND ROBOTIC SURGERY: OUR
Conclusion: Vaginal cuff dehiscence with RALH is similar to that reported in the EXPERIENCE Mario Villa, MD, Michela Teruzzi, MD, Ciro Sportelli,
literature for laparoscopic hysterectomy. In our study, robotic hysterectomy is MD, Francesca Fei, MD, Giovanna Caspani, MD, Sara Sacco, MD, Antonio
not associated with an increased risk of cuff dehiscence. Pellegrino, MD Azienda Ospedaliera Ospedale Provinciale di Lecco, Italy
Introduction: Endometrial cancer is the most common female malignancy (6%)
P088: USE OF INTRAUTERINE MANIPULATOR AND ITS EFFECT ON (1). Robotic-assisted laparoscopic hysterectomy seems to overcome standard
LYMPHOVASCULAR SPACE INVASION IN ROBOTICALLY ASSISTED laparoscopy problems (2). Feasibility and safety are objectives of our analysis.
ENDOMETRIAL CANCER STAGING Rhoda A Raji, MD, Karim ElSahwi,
MD, Charlene Hooper, MD MPH, Elena Ratner, MD, Dan-Arin Silasi, MD, Methods & Procedures: Between January 2010 to December 2010, twelve patients
Peter E Schwartz, MD, Thomas J Rutherford, MD PhD, Masoud Azodi, MD with diagnosis of early endometrial cancer, were enrolled in our study; pre-
Yale-New Haven Hospital, New Haven, CT, 06520 , USA. operative work-up included clinical check, ultrasound scan, office hysteroscopy
with endometrial biopsy, pelvis and abdomen MRI and chest radiography.
Objectives: To evaluate the association between the use of a uterine manipulator They underwent robotic surgery (total hysterectomy with bilateral salpingo-
and lymphovascular space invasion (LVI) in robotically assisted staging for oophorectomy) at Manzoni Hospital, Lecco, Italy. Frozen section is used to
endometrial cancer. define who needs pelvic staging. Three patients received pelvic node dissection.

58 6 TH ANNUAL MIRA CONGRESS May 11-13, 2011


Results: Twelve consecutive patients were submitted to robotic extrafascial be attributable to the difficulty in making secure ties when using laparoscopic
hysterectomy with bilateral salpingo-oophorectomy for early stage endometrial method. To prevent recurrence and maintain the benefit of minimally invasive
cancer. Mean patient age was 58,6 yeras (range 49-66), BMI was 26,72 kg/m2 surgery, we performed a robotic repair and reinforcement with porcine dermal
(21,45-34,67), mean operating time was 168 minutes (80-310), mean docking collagen implant (Permacol®) for an infantile giant hiatal hernia.
time was 8,83 minutes (4-17), mean blood loss was 20 mL (10-150), mean Methods & Procedures: A three-month-old 6.9 kg boy with an incidental hiatal
hospital stay was 1,2 days (1-2). No procedure was converted to laparotomy. No hernia was presented for further evaluation and treatment. An esophageal
complications are reported. contrast study and chest CT depicted near total gastric herniation through a
Conclusions: Treatment of early-stage endometrial cancer is surgery: total giant hiatal defect. After verification of pathologic gastroesophageal reflux
hysterectomy, BSO and staging, if necessary. Laparoscopic technique is standard with 24-hr esophageal pH monitoring, robotic repair of the hiatal hernia using
procedure and it proves as safe and feasibile as laparotomy (3-4) with longer learning da Vinci® system was performed. Two thirds of the stomach was herniated to
curve. Da Vinci approach offers shorter learning curve (5) with technical advantages large hiatal defect. After repairing the defect using interrupted non-absorbable
(three dimensional visualization, increased degrees of motion, improved dexterity, sutures, the diaphragmatic crura was reinforced using the Permacol® patch.
elimination of tremor, surgeon comfort). Many study were published about Robotic Nissen fundoplication was also done. Total operation time was 340 minutes, and
surgery, comparing it with laparoscopy (7) and laparotomy (6-8). With less blood the console time was 270 minutes.
loss, shorter hospital stay, robotic surgery seems to be the best approach; operative Results: The patient was discharged in fifth day after the operation without any
time was significantly longer in the robotic group when compared with open- complications. No evidence of recurrence was observed during the follow-up
surgery, but lower morbidity, feasibility and safety justify its use. period.
Although little series, our results confirm that robotic procedure could be Conclusions: Robotic repair and reinforcement of diaphragmatic crura with
standard approach for treatment of early stage endometrial cancer. porcine dermal collagen implant (Permacol®) for an infantile hiatal hernia is
Bibliography: a safe and feasible method to prevent recurrence and maintain the benefits of
1) Jemal et al, Cancer statistics 2007. CA Cancer J Clin. 2007; 57: 43-66 minimally invasive surgery.
2) Kho et al, Robotic hysterectomy: tecnique and initial outcomes, Am. J Obstet
and Gynecol 2007; 197: e1.113-4 P093: THE EXPERIENCE OF THE 2ND UROLOGY DEPARTMENT AT
3) Kornblith et al. QOL of patients with endometrial cancer undergoing HYGEIA HOSPITAL IN ROBOTIC SURGERY Alexandros Mokakos, MD,
laparoscopic international federation of gynecology and obstetrics staging Spiridon Martinis, MD, Emanuel Panagiotou, MD 2nd Department of Urology,
compared with laparotomy: GOG study. J Clin Oncol 2009;27:5337-42 Hygeia Hospital, Athens Greece
4) Walker et al. Laparoscopy compared with laparotomy for comprehensive Purpose: To report the experience of 2nd Urology department of Hygeia Hospital
surgical staging of uterine cancer: GOG study LAP 2. J Clin Oncol in Urological Robotic Surgery.
2009;27:5331-36
5) Cho et al, Robotics and Gynecologic Oncology: review of the literature, J Methods & Procedures: Since June 2007, over 300 patients underwent a various
Minim Invasive Gynecol 2009;16(6):669-81 number of urological robotic surgeries (radical prostatectomies, simple or
6) Gehrig PA et al, What is the optimal minimally invasive surgical procedure radical nephrectomies, partial nephrectomy, radical and partial cystectomy,
for endometrial cancer staging in the obese? Gynecol Oncol. 2008; 111:41-5 pyeloplasty, kidney cyst, varicocele, BPH and a rare case of a giant multilocular
7) Veljovich et al robotic surgery in gynecologic oncology: program initiation cystedenoma of the prostate).
and outcomes after the first year with comparison with laparotomy for Results: The radical prostatectomies (275) were performed with transperitoneal
endometrial cancer staging. Am J Obstet and Gynecol. 2008; 198:679.e1-e.10 approach. Two cases had to be open. The average surgical time, blood loss,
8) De Nardis et al Robotically assisted laparoscopic hysterectomy versus total hospital stay and catheter time was 168 min, 142 ml, 2.5 days and 12 days
abdominal hysterectomy and lymphadenectomy for endometrial cancer. Gynecol respectively. 85 % had good erectile function in the first year and 98 %
Oncol. 2008; 111:412-7 was continent. Complications : 1 ureter injury, 2 post – OR bleeding, 1
thrombosis and 1 pulmonar embolie. The radical nephrectomies (11) were done
P091: LAPAROSCOPIC AND ROBOTICALLY ASSISTED transperitoneally and no case was transformed to open. The mean age OR-time,
HYSTERECTOMY. OUR EXPERIENCE IN A SERIES OF 8 CONSECUTIVE tumor size, blood loss and hospital stay was 68 yrs, 158 min, 6.1 cm, 183 ml
CASES. Konstantinos P Mirillas, MD, Petros C Hiridis, MD, Bisbikis Dimitris, and 2.4 days respectively. In the partial nephrectomies (7) the average OR-time
MD, Savas C Hiridis, MD MSc, Perikles S Chrysocheris, MD, Konstantinos M was 191 min, the mean ischemia time 25.6 min and the mean hospital stay 2.9
Konstantinidis, MD PhD FACS ATHENS MEDICAL CENTER days. Duration of the pyeloplasties was 120 – 180 min with 1-2 days hospital
Objective: To assess robotically assisted laparoscopic hysterectomy in patients with stay and without complications. 12 patients underwent radical cystectomy and
benign conditions in comparison to conventional laparoscopic hysterectomy. ileal conduit urinary diversion or ureterostomies. The bowel part was done
open in only two patients. OR duration was 240 – 415 min, hospital stay 6 – 11
Study Design: Retrospective study of 42 patients undergoing robotic (n=8) or days without any major complications. Adenoma enucleation for benign prostate
laparoscopic (n=34) hysterectomy. Data included uterus weight, total vs subtotal hyperplasia occurred in 10 patients. Duration was 100 – 180 min, hospital stay
hysterectomy, pathological findings, skin-to-skin operative time, estimated 2 – 3 days and catheter indwelling time 6 – 7 days. One patient with a giant
blood loss, complications, and postoperative hospitalization length. All multilocular cystadenoma of prostate underwent radical prostatectomy.
hysterectomies were performed by the same surgeon.
Conclusions: In our department almost all the cases are done robotically with Da
Results: All robotic hysterectomies were completed with no conversion to Vinci - S system, with safety, success and great efficacy.
laparotomy. The average uterus weight was 415g respectively.The mean and
range of the operating time was 145min for robotic and 115 min for laparoscopic P094: ROBOTIC-ASSISTED RADICAL PROSTATECTOMY IN MEN OVER
hysterectomy. The estimated blood loss was less in the robotic method, due to 75 YEARS OF AGE. SURGICAL, ONCOLOGIC AND FUNCTIONAL
the effective combination of monopolar and bipolar electrocoagulation. OUTCOMES. Apostolos P Labanaris, MD PhD, Vahudin Zugor, MD PhD,
Conclusion: Robotic-assisted hysterectomy (RAH) is feasible and safe for women Jorn H Witt, MD PhD Department of Urology and Pediatric Urology - Prostate
with benign uterine pathology. Center Northwest, St. Antonius Medical Center, Gronau, Germany
Introduction: The aim of this study is to evaluate the surgical, oncologic and
P092: ROBOTIC REPAIR AND REINFORCEMENT WITH PERMACOL® functional outcomes in men ≥ 75 years of age undergoing robot-assisted radical
OF GIANT HIATAL HERNIA IN AN INFANT Eun Young Chang, MD, Jae prostatectomy (RARP).
Ho Shin, MD, Hye Kyung Chang, MD PhD, Jung-Tak Oh, MD PhD, Seok Joo
Han, MD PhD Department of Pediatric Surgery, Severance Children’s Hospital, Methods & Procedures: The records of N=2000 men who underwent RARP
Yonsei University College of Medicine, Seoul, Korea at a certified robotic institute from February 2006 to April 2010 were
retrospectively reviewed. A total of N=45 (2,25%) were ≥ 75 years of age.
Introduction: The recurrence rate in laparoscopic hiatal hernia repair is reported A comparison was performed between the overall patient cohort and the
to be higher than in conventional open method. This high recurrence rate may
www.mirasurgery.org 59
Poster Abstracts
aforementioned patients. The parameters analyzed included: age, body-mass P096: ROBOTIC RADICAL AND PARTIAL NEPHRECTOMY Nick
index (BMI), prostate weight, PSA values, bilateral neurovascular bundle (NVB) Pardalidis, Nick Andriopoulos, Aggelos Karamanis, Eleni Kosmaoglou Athens
preservation, estimated blood loss, minor (Clavien’s grade I–IIIa) and major Medical Centre, Athens, Greece
complications (Clavien’s grade IIIb-IVa), skin-to-skin operative time, length Objectives: We present our experience using the da Vinci system in renal tumors,
of catheterisation, Gleason score, pathologic stage, percentage of PCa found in performing radical as well as partial nephrectonies.
the prostate specimen, positive margin status, continence (defined as no pad
use) and potency (defined as erections sufficient for penetration with or without Materials & Methods: Since 2006, 20 patients successfully underwent radical
phosphodiesterase inhibitors) nephrectomy for renal tumors, using transperitoneal approach. Our only
limitation was the size of the tumor (less than 4cm). We have also performed 8
Results: A statistical difference of the parameters analyzed was not observed. partial nephrectomies at the same period, for solitary small renal tumors ’4cm.
The median BMI was 26.7 kg/m2 / 26.9 kg/m2, the median prostate weight
was 56.1 gr. / 52.8 gr. and the median PSA value was 10.3 ng/ml / 9.3 ng/ml. Results: The mean operative time(console time) for radical nephrectomy was
A bilateral NVB preservation was performed in 65.7% / 51.1% of cases and 165 min, blood loss 275 ml, mean tumor size was t.8 cm and mean hospital stay
the estimated blood loss was 160ml / 131ml. Minor complications were noted was 2.8 days. Renal vessels were ligated either with haemolock clips or steplers.
in 11.4% / 15.5% of cases and major in 1.3% / 2.2%. The median operative No intra operative complications were encountered. For partial nephrectomy
time was 156 min / 143 min and the length of catheterisation was 5.5 days / procedures hilar clamping was used with a mean warm ischemia of 30 min.
6.1 days. A Gleason score < 7 was noted in 42.8% / 37.3%, a Gleason score 7 The mean operative time was 168 min, mean blood loss was 280 ml and mean
in 47.7% / 51.1% and a Gleason score > 7 in 9.5% / 11.6%. A organ-confined hospital stay of 3.2 days
disease in was noted in 73.5% / 68.8%, extraprostatic extension in 25.2% / Conclusions: da Vinci radical as well as partial nephrectomy is a safe and effective
31.2% and a positive surgical margin status was encountered in 8.9% / 11.1% method for the management of renal cancer.
of cases. The percentage of PCa found in the prostate specimen was 16.1% /
17.8%. At 12 months, 92.8% / 86.9% were continent and 66.2% / 39.6 % P097: RETROSPECTIVE STUDY ON ANATOMIC VARIATIONS OF
(p<0.001) of preoperative potent patients who underwent NVB preservation RENAL VESSELS BASED ON LAPAROSCOPIC-ROBOTIC SURGERY
were potent. EXPERIENCE Chady Waked, MD, Ibrahim-Michel Karam, MD, cyril
Conclusions: Our findings suggest that RARP in patients ≥ 75 years of age is a Perrenot, MD, Manuella Perez, MD, Pascal Eschwege, MDPhD, Michel
safe surgical procedure with limited complications and excellent oncologic and Claudon, MDPhd, Jacques Hubert, MDPhD Department of Urology, Brabois
continence outcomes. Even so radical prostatectomy in patients older than 75 Hospital, Nancy, France
years should be limited to a selected collective with a good health status and Purpose: Evaluate the impact of the three-dimensional imaging on the dissection
an individual life expectancy of more than 10 year to achieve the oncological of renal vessels and demonstrate the capacity of laparoscopic-robotics’ approach
advantages of the surgery. on identifying and preserving these vessels mainly in the case of atypical vascular
variations and difficult and complex tumour localisation.
P095: EVALUATION OF SURGICAL MARGIN STATUS IN PATIENTS
UNDERGOING ROBOTIC-ASSISTED RADICAL PROSTATECTOMY FOR Methods & Equipment: The study was conducted on 100 cases of renal transplant
LOW, INTERMEDIATE, AND HIGH-RISK PROSTATE CANCER. Apostolos with living donor and 60 partial nephrectomies. A multislice CT scan
P Labanaris, MD PhD, Vahudin Zugor, MD PhD, Jorn H Witt, MD PhD with 3D reconstruction based on MPVR technique with axial and oblique
Department of Urology and Pediatric Urology - Prostate Center Northwest, St. reconstructions on the vessels level was performed on each patient. The
Antonius Medical Center, Gronau, Germany laparoscopic surgery was performed with a three arms Da Vinci Robot. We
compared imaging results with anatomic reality observed in intraoperative and
Introduction: Although the past years robot-assisted radical prostatectomy evaluated the role of 3D imaging on making the dissection of hilum and renal
(RARP) has become profoundly popular, some urologists remain sceptic tumours easier.
regarding the lack of tactile sensation and subsequently a possible increase of
positive surgical margins (PSM). The objective of this study is to evaluate the Results: We found many variations in the renal venous system: multiple veins on
surgical margin status in patients undergoing RARP for low, intermediate, and the right side, on the left side we found some retro-aortic veins and circum-
high-risk prostate cancer (PCa). aortic venous rings. The arterial vascularisation results from a single artery
in 75% of cases, two arteries in 20% and three arteries in 5% of cases. The
Methods & Procedures: The records of N=2000 men who underwent RARP modality of division of the renal arteries is inconstant, but the bifurcation in
at a certified robotic institute from February 2006 to April 2010 were an anterior branch and a posterior branch are relatively constant. Our method,
retrospectively reviewed. A total of N=125 patients were identified as having a based on 3D imaging and laparoscopic-robotic approach, reduced to null the
low risk PCa (Gleason ≤ 6, PSA < 10 ng/ml, T1c-T2a), N=825 an intermediate level of conversion and intraoperative bleeding.
(Gleason 7, PSA 10–20 ng/ml, T2b) and N=1050 a high risk PCa (Gleason >7,
PSA >20 ng/ml, >T2b). The parameters analyzed included PSM rates according Discussion: The multiphasic acquisition, with multi slice CT scan 3D
to low risk PCa, intermediate risk PCa, high risk PCa and pathologic stage. reconstruction permitted the establishment of an intraoperative cartography of
Patients with cT3 disease or Gleason score ≥ 8 or PSA > 20ng/ml underwent the vessels number and situation resulting in an easier dissection in the reduced
wide excision of the neurovascular bundles. PSM were defined as cancer at the operative field. The 3D CTscan images and 3D robotic coupling leads operator
inked resection margin. to conduct a selective dissection of renal vessels and overcome difficulties
represented by the atypical anatomic configuration. Furthermore, during partial
Results: The overall PSM rate was 8.1% (N=162 patients). PSM was evident in nephrectomy, the three-dimensional scanographic imaging allows the surgeon to
N=1 (0.8%) of low risk, N=27 (3.2%) of intermediate risk and N=134 (12.7%) have a pre-operative clear vision as for the tumour localisation, its deepness and
of high risk PCa patients. According to pathologic stage, PSM were noted in vascularisation. This imaging, associated with three-dimensional and robotic
3.1% of pT2 cases (45 of 1484 pT2 patients), 16.1% of pT3 cases (73 of 455 pT3 arms articulation, enables a better dissection of the tumour and renal hilum, and
patients) and 72.1% of pT4 cases (44 of 61 pT4 patients). helps the surgeon to control an eventual selective tumour artery.
Conclusions: Our findings suggest that patients with a low or intermediate risk Conclusion: This study demonstrated that 3D imaging provides high quality
PCa undergoing RARP from experienced surgeons exhibit an excellent surgical images that make intraoperative anatomic analyzes more accessible to those
margin status. In patients with a high-risk PCa or a ≥ pT3 pathologic stage, the non-specialized in imaging mainly urologists. The interest of the excellent
surgical margin status can be surely considered as acceptable. correlation between three-dimensional representation and the intraoperative
vision is to give to the operator the capacity to anticipate difficulties and
overcome them.
Key Words: multislice CT scan, three-dimensional reconstruction, Da Vinci
Robot, robotic simulation, renal veins, renal arteries, partial nephrectomy.

60 6 TH ANNUAL MIRA CONGRESS May 11-13, 2011


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