To develop and validate a novel Comorbidity score for Robotic Surgery (CRS) in predicting severe complications after robot-assisted radical prostatectomy (RARP). Furthermore, we investigated the impact of the surgical platform (Multi-Port - MP vs Single-Port - SP) according to this score. We included 2085 ("development cohort") and 595 ("validation cohort") patients undergoing RARP at two tertiary referral centers between 2014 and March 2024 in a retrospective study. Statistical analyses included validation of the Charlson Comorbidity Index (CCI) to predict 30-day severe complications (Clavien-Dindo ≥ 3a), development and external validation of CRS using calibration plots and decision curve analysis. Lastly, locally weighted scatterplot smoothing (LOWESS) analysis was used to graphically explore the impact of the robotic platform according to novel CRS. CCI exhibited limited predictive ability for severe complications (60% in the validation cohort). In multivariable logistic regression analyses testing the correlation between each condition included in CCI and severe complications, diabetes and myocardial infarction resulted as independent predictors (OR 1.75 [95%CI 1.05-2.82]; OR 1.92 [95%CI 1.26-2.88]) and were subsequently fitted into a multivariable logistic model including age, previous abdominal surgery and obesity (BMI > 30). The resulting predictive model demonstrated superior discrimination and clinical net benefit in predicting severe complications compared to CCI (AUC 64 vs 60%). At LOWESS analysis, SP platform was associated with lower risk of severe complications as CRS increased compared to MP system. The validated CRS showed better accuracy compared to CCI in predicting severe complications after RARP. Additionally, the use of SP robotic platform may reduce the risk of severe complications in highly comorbid patients according to CRS.

Nissen fundoplication (NF) is a common surgical procedure to treat gastroesophageal reflux disease; however, a subset of patients may continue to experience symptoms or develop symptom recurrence despite a successful procedure. This study aims to compare laparoscopic and robotic approaches for treating failed NF and evaluate the outcomes after converting to Toupet fundoplication (TF). We conducted a retrospective analysis of patients who underwent robotic or laparoscopic revision to TF for failed NF between 2016 and 2023. The data collected included demographics, pre-operative workup, and peri- and post-operative outcomes. Symptom analysis and anti-reflux medication usage were collected using a patient questionnaire. Failed fundoplication was defined as the need for an additional operation due to unresolved GERD symptoms or the emergence of a new issue. Eighty-eight patients (56 laparoscopic, 32 robotic) were included. Mean operative time was 148.71 ± 53.64 min for the total cohort and was significantly longer in the robotic group (RG) 167.43 min vs 138.01 min in the Laparoscopic group (LG) (p value = 0.012). The LG had a length of hospital stay of 2.16 ± 1.69 days vs RG 2.21 ± 1.28 days (p value = 0.867). The LG had a higher number of early readmissions (5.4%, p value = 0.629) and both the LG and the RG had 1 patient that required an early reintervention. Symptoms of dysphagia and reflux decreased in both groups at last follow-up, but the reduction in PPI use was not significant. Surgical revision to TF for failed NF provides significant symptom improvement with low rates of complications and recurrences. Our study shows that both approaches are safe and feasible and have comparable surgical and symptom outcomes.

This study aimed to assess the safety and feasibility of the Robocare nursing model in patients undergoing da Vinci robot-assisted radical gastrectomy for gastric cancer. A total of 68 patients who underwent da Vinci robot-assisted radical gastrectomy for gastric cancer in our department from January 2022 to June 2022 were enrolled in this study and were assigned to a control group (n = 34) and an intervention group (n = 34). The control group received standard perioperative nursing care, while the intervention group received the Robocare model along with standard care. We compared the differences in postoperative hospital stay length, the incidence of postoperative complications, readmission rates within one month after discharge, and satisfaction with nursing care between the two groups. Compared to the control group, patients in the intervention group exhibited a significantly shorter postoperative hospital stay (mean 8.94 days vs. 9.76 days, P < 0.05) without an increase in the incidence of postoperative complications (26.5% vs. 29.4%, P > 0.05). In addition, there was no significant difference in readmission rates within 1 month after discharge between the two groups (14.7% vs. 5.9%, P > 0.05). Patient satisfaction was significantly higher in the intervention group compared to the control group (96.34% vs. 91.96%, P < 0.05). The implementation of the Robocare nursing model for patients undergoing da Vinci robot-assisted radical gastrectomy for gastric cancer may reduce the length of postoperative hospital stays without increasing the incidence of postoperative complications, while also enhancing patient satisfaction with nursing care.

The robotic surgeon is at risk of visual fatigue from prolonged viewing of the video display resulting in digital eye strain and use of the three-dimensional binoculars resulting in accommodative stress. Symptoms of digital eye strain include blurred vision, dry eyes, eyestrain, neck and back ache, diplopia, light sensitivity, and headaches. Vergence or accommodation-related symptoms include blurred near or distance vision, difficulty refocusing, and diplopia. Beneficial ergonomic interventions to manage digital eye strain during robotic surgery include appropriate lighting, improved neck positioning, optimal screen positioning, improved image parameters, screen breaks, optimising environmental factors, and eye exercises. Correction of refractive error, use of lubricating eye drops, and blink efficiency training to induce motor memory have been shown to be effective in reducing visual fatigue. Vergence-accommodation mismatch can be reduced with slower movement of the camera, screen breaks, and correction of refractive error. Robotic surgeons should adopt these simple and non-invasive interventions to minimise visual fatigue.

Telesurgery, the remote execution of surgical procedures through telecommunication and robotic systems, has witnessed substantial growth in recent years, promising to address global healthcare disparities and enhance surgical expertise. This paper explores the humanitarian and surgical benefits of telesurgery, emphasizing its potential to provide expert surgical care to underserved regions. Despite its transformative potential, telesurgery faces significant technologic challenges, including issues of data transmission, latency, and the need for advanced robotic platforms. The advent of 5G networks and innovative robotic systems provides a promising technological landscape, yet global disparities in 5G coverage remain a concern. Ethical considerations, ranging from preserving the surgeon-patient relationship to addressing patient vulnerability and conflicts of interest, are pivotal aspects that demand attention. The paper underscores the importance of clear regulatory frameworks and international collaboration to navigate legal complexities and ensure ethical standards. As telesurgery progresses, integrating artificial intelligence, augmented reality, and haptic feedback technologies holds promise for further advancements. Despite these challenges, telesurgery has the potential to achieve equitable access to expert surgical care; however, it requires a collective effort to overcome its intricate technologic and administrative hurdles.

Artificial intelligence (AI) has emerged as a transformative tool in surgery, particularly in telesurgery and telementoring. However, its potential to enhance data transmission efficiency and reliability in these fields remains unclear. While previous reviews have explored the general applications of telesurgery and telementoring in specific surgical contexts, this review uniquely focuses on AI models designed to optimise data transmission and mitigate delays. We conducted a comprehensive literature search on PubMed and IEEE Xplore for studies published in English between 2010 and 2023, focusing on AI-driven, surgery-related, telemedicine, and delay-related research. This review includes methodologies from journals, conferences, and symposiums. Our analysis identified a total of twelve AI studies that focus on optimising network resources, enhancing edge computing, and developing delay-robust predictive applications. Specifically, three studies addressed wireless network resource optimisation, two proposed low-latency control and transfer learning algorithms for edge computing, and seven developed delay-robust applications, five of which focused on motion data, with the remaining two addressing visual and haptic data. These advancements lay the foundation for a truly holistic and context-aware telesurgical experience, significantly transforming remote surgical practice and education. By mapping the current role of AI in addressing delay-related challenges, this review highlights the pressing need for collaborative research to drive the evolution of telesurgery and telementoring in modern robotic surgery.

The purpose of this study is to explore the risk factors for conversion from minimally invasive surgery to thoracotomy in patients with lung cancer through meta-analytic approach, and provide a better evidence-based basis for clinicians to perform surgery. We conducted a comprehensive search across databases including PubMed, Embase, Web of Science, and the Cochrane Library database to identify relevant English-language studies published up to February 2024. The pooled effect estimate was calculated using the odds ratio (OR) and a 95% confidence interval (CI). We also conducted sensitivity, subgroup, and publication bias tests. Meta-analysis was performed by using stata18MP software. The study was registered with PROSPERO(ID: CRD42024524790). We included a total of 8 studies. We discovered that gender (OR: 1.58; 95% CI: 1.23-2.03; P < 0.001), chronic obstructive pulmonary disease (COPD) (OR: 1.13; 95% CI: 1.04-1.23; P = 0.005), location of the tumor (OR: 1.21; 95% CI: 1.12-1.31; P < 0.001) were all linked to an increased risk of conversion. Additionally, the type of surgery (OR: 0.14; 95% CI: 0.05-0.39; P < 0.001) was associated with a reduced risk of conversion. Nevertheless, age, smoking, and obesity showed no association with the risk of conversion. The current meta-analysis suggests that the male gender, COPD, upper lobe tumor location, and the video-assisted approach are risk factors for conversion from minimally invasive surgery to thoracotomy in patients with lung cancer. More high-quality studies are required to validate the above results due to the limited number and types of studies included.

The Hugo robotic assisted surgery system is a relatively new robotic platform developed by Medtronic. The study objective was to describe the experience of using Hugo robotic assisted surgery in gynecological surgeries and compare robotic assisted surgery-related outcomes between complex and non-complex gynecological patients at the Pacifica Salud Hospital. We performed secondary data retrospective analysis of 144 consecutive patients who underwent gynecological surgery with Hugo robotic assisted surgery system (Medtronic) at the Pacifica Salud hospital in Panama City from July 19, 2021, to August 3, 2023. Complex patients were defined as those with one or more risk factors for surgery complications. Descriptive analysis of participants' sociodemographic and robotic assisted surgery-related characteristics. Due to the non-normal distribution of the RAS-related numeric variables, we compared these variables between complex and non-complex cases of gynecological patients using Kruskal-Wallis's test. The study found that Hugo robotic assisted surgery system was safe for gynecological surgery in patients with and without risk factors for developing major surgery complications. None of the patients experienced any complications, and they had short hospital stays with low blood loss without requiring a blood transfusion. The Hugo robotic assisted surgery system was technically sound and did not present technical failures. The results could be a reference for adopting this technology and developing best practices in the Latin American region.

Single-port (SP) robotic surgery is a novel technology, and although there is emerging data, it remains limited in assessing single-port (SP) robot-assisted surgery as an alternative to multi-port (MP) platforms. To compare perioperative and postoperative outcomes between SP and MP robotic technologies for radical nephrectomy (RN). This is a retrospective cohort study of patients who have undergone robot-assisted radical nephrectomy using either the SP or MP technology. Baseline demographics, clinical, tumor-specific characteristics, and perioperative and postoperative outcomes were compared using χ, t-test, Fisher exact test, and Mann-Whitney U test. Multivariable analyses were conducted using robust, Poisson, and logistic regressions. A total of 341 patients underwent robotic RN with 47 patients (14%) in the SP group. The two groups exhibited similar baseline characteristics, with no significant differences in age, sex, body mass index, Charlson comorbidities index, and tumor laterality. However, SP group had a smaller average tumor size (5.1 cm vs 6.4 cm, p = 0.009). The SP had longer operative time (178 ± 84 min vs 142 ± 75 min; p = 0.011) but showed no significant difference in the estimated blood loss, blood transfusion rate, length of stay, overall 30-day and major complication rates. Controlling for other variables, SP was significantly associated with a longer operative time and shorter length of stay. SP is associated with longer operative time but offers advantages such as smaller incisions and shorter hospital stays with a comparative safety profile to MP for radical nephrectomy.

Previous studies have compared single-port robotic cholecystectomy (SPRC) to single-incision laparoscopic (SILC). However, there is not a systematic review and meta-analysis in patient with BMI ≥ 25 kg/m even though higher BMI is a risk factor for gallstone disease, a common indication for cholecystectomy. PubMed, Scopus and Cochrane Library were searched for related literature. Studies and data were extracted by two independent reviewers. Inverse variances weighted mean differences (WMD) with random effects model were used for continues values and odds ratios (OR) with random effects model using the Mantel-Haenszel's formula were used for dichotomous value. Heterogeneity using Higgins I and p values were calculated. Sensitivity analysis was performed for operative duration and intraoperative complications. In this meta-analysis, six studies involving a total of 734 patients examined SPRC and SILC. The analysis revealed a statistically significant increase in operative duration for SPRC compared to SILC, with a weighted mean difference of 26.67 min (95% CI 14.99, 38.34; I = 93%; P < 0.00001; P < 0.00001). Regarding conversion to multi-port cholecystectomy (MC), no statistically significant difference was found, yielding an odds ratio of 0.94 (95% CI 0.36, 2.45; I = 0%; P = 0.78; P = 0.89). Intra-operative blood loss showed non-significant differences, with a weighted mean difference of - 16.76 ml (95% CI - 48.56, 15.03; I = 78%; P = 0.03; P = 0.30). Length of hospitalization was significantly reduced by approximately half a day for SPRC compared to SILC, with a weighted mean difference of - 0.52 days (95% CI - 0.89, - 0.14; I = 0%; P = 0.52; P = 0.007). Intra-operative complications did not differ significantly between the techniques, resulting in an odds ratio of 0.59 (95% CI 0.19, 1.81; I = 70%; P = 0.04; P = 0.36). Finally, two studies evaluated bile leak rates, concluding no significant difference with an odds ratio of 0.86 (95% CI 0.39, 1.88; I = 23%; P = 0.25; P = 0.70). Sensitivity analyses indicated that no single study unduly influenced the results for operative duration, while one study was identified as a source of heterogeneity in intra-operative complications. SPRC is associated with longer operative duration, but shorter length of hospitalization in patients with BMI ≥ 25 kg/m, compared to laparoscopic. Future studies should aim to examine incisional hernias rates as well as determine the long-term outcomes. PROSPERO registration: CRD42024602514.

To determine risk factors for urinary retention (UR) after robot-assisted radical cystectomy (RALC) with orthotopic neobladder diversion. A total of 269 patients who underwent RALC with orthotopic neobladder diversion from 2008 to 2019 at seven tertiary hospitals were retrospectively analyzed. There were 68 patients who had UR (UR arm) and 201 patients who did not have UR (no-UR arm). UR was defined as voiding dysfunction without catheterization or more than 100 mL of residual urine after voiding. Preoperative demographics, perioperative factors, pathology outcomes, and postoperative complications of UR and no-UR arms were compared and predictors of UR were identified. Among demographic factors, only gender proportion showed a difference, with male proportion being significantly lower in the UR arm than in the no-UR arm (81% vs 92%, p = 0.010). For perioperative outcomes, anastomosis site stricture (27% vs 11%, p = 0.003) and length of hospital stays (23 days vs. 19 days, p = 0.001) were significantly higher in the UR arm than in the no-UR arm. In multiple logistic regression analysis, female (OR 3.32, 95% CI: 1.43-7.72) and body mass index (BMI) (OR 1.10, 95% CI 1.00-1.20) were UR predictors. UR after RALC with orthotopic neobladder diversion is significantly increased in females. Multiple logistic regression analysis identified female and BMI elevation as UR predictors.

This paper explores the role of 5G-and future 6G networks-in advancing robotic telesurgery by minimizing latency and enhancing data reliability for real-time remote operations. With robotic telesurgery gaining prominence as a tool to democratize access to specialized surgical care, telecommunications infrastructure has become central to its feasibility and safety. Key elements include 5G's capacity for ultra-low latency and high data transfer rates, which support critical modalities such as kinesthetic, audiovisual, and tactile feedback in telesurgery. The paper outlines the differing latency demands of these modalities, noting that kinesthetic data are particularly sensitive, requiring ultra-low latency for effective surgeon feedback. In addition, the paper discusses the importance of network reliability and Quality-of-Service (QoS) agreements, alongside the potential for 6G networks to further reduce latency and integrate AI-driven predictive analytics. These advancements are positioned to not only broaden telesurgery's reach but also to enhance the precision and safety of procedures, setting the stage for a new paradigm in remote surgical care.

Minimal-invasive surgery (MIS) and robotic surgery (RS) offer multiple advantages over open surgery (Vajsbaher et al. in Cogn Syst Res 64:08, 2020). However, the lack of haptic feedback is still a limitation. Surgeons learn to adapt to this lack of haptic feedback using visual cues to make judgements about tissue deformation. Experienced robotic surgeons use the visual interpretation of tissue as a surrogate for tactile feedback. The aim of this review is to identify the visual cues that are consciously or unconsciously used by expert surgeons to manipulate soft tissue safely during Minimally Invasive Surgery (MIS) and Robotic Surgery (RS). We have conducted a comprehensive literature review with papers on visual cue identification and their application in education, as well as skill assessment and surgeon performance measurement with respect to visual feedback. To visualise our results, we provide an overview of the state-of-the-art in the form of a matrix across identified research features, where papers are clustered and grouped in a comparative way. The clustering of the papers showed explicitly that state-of-the-art research does not in particular study the direct effects of visual cues in relation to the manipulation of the tissue and training for that purpose, but is more concentrated on tissue identification. We identified a gap in the literature about the use of visual cues for educational design solutions, that aid the training of soft-tissue manipulation in MIS and in RS. There appears to be a need RS education to make visual cue identification more accessible and set it in the context of manipulation tasks.

The development of Artificial Intelligence (AI) is one of the most revolutionary changes in modern history. The combination of AI and Robotic surgery can be used positively for better patient outcomes.

Transoral robotic surgery (TORS) has become a common surgical approach for the treatment of both benign and malignant conditions of the oropharynx. While the newer da Vinci Xi platform has largely replaced the previous Si model in many institutions, the reported outcomes with this system in head and neck surgery are limited. We report the feasibility of using the da Vinci Xi platform for managing oropharyngeal cancer and obstructive sleep apnea in a low-volume center. This retrospective review from a consecutive case series includes demographic, procedural, and outcome data from all patients who underwent TORS using the da Vinci Xi platform at a single institution over a 5-year period from 2019 to 2023. Thirty-five patients (19 males and 16 females) underwent TORS for a variety of indications. No patients were excluded from the study. There were no mortalities, readmissions, or severe complications directly related to the primary surgery. Our case series demonstrates that TORS is feasible with the da Vinci Xi system even in low-volume centers and supports the existing data suggesting that the Xi platform has an acceptable safety profile.

Miscommunication in the OR is a threat to patient safety and surgical efficiency. Our objective was to measure the frequency and causes of communication interference between robotic team members. We observed 78 robotic surgeries over 215 h. 65.4% were General Surgery, most commonly cholecystectomy, identifying Speech Communication Interference (SCI) events, defined as "surgery-related group discourse that is disrupted according to the goals of the communication or the physical and situational context of the exchange". We noted the causes and strategies to correct the miscommunication, near misses, and case delays associated with each SCI event. Post-surgery interviews supported observations and were analyzed thematically. Overall, we observed 687 SCI events (mean 8.8 ± 6.5 per case, 3.2 per hour), ranging from one to 28 per case. 48 (7.0%) occurred during docking and 136 (19.8%) occurred during a critical moment. The most common causes were concurrent tasks (66.1%); loud noises (10.8%) from patient cart, lightbox fan, and suction machine; and overlapping conversations (4.2%). 94.8% resulted in a case delay. These events distracted from monitoring patient safety and resulted in near misses. Mitigating strategies included leaning out of the surgeon console to repeat the message and employing a messenger. These findings help characterize miscommunication in robotic surgery. Possible interventions include microphones and headsets, positioning the surgeon console closer to the bedside, moving loud equipment further away, and upgrading the patient cart speaker.

Little is known about the incidence of subcutaneous emphysema (SE) after robotic cardiac surgery. The aim of this study was to describe the incidence, identify risk factors, and assess its influence on postoperative outcomes. Patients undergoing robotic mitral valve repair (n = 63, 54.3%), robotic minimally invasive direct coronary artery bypass grafting (n = 23, 19.8%), and robotic totally endoscopic coronary artery bypass grafting (n = 30,25.9%) were included in the analysis (total n = 116). Subcutaneous emphysema occurred in 53/116 patients (45.7%). It was mild in 30/53 patients (56.6%), moderate in one patient (1.9%), and severe in 22/53 patients (41.5%). Low body weight (p = 0.009), low BMI (p = 0.006), small body surface area (p = 0.01), and older age (p = 0.041) significantly correlated with SE. Patients undergoing robotic mitral valve repair were affected more often than patients undergoing robotic coronary artery bypass grafting (p = 0.04). Severe subcutaneous emphysema resulted in an increased need for CT-chest imaging (p = 0.026), and additional chest tubes (p = 0.029). Severe emphysema was highly associated with pneumothorax (p < 0.001) and increased duration of chest tube drainage (p = 0.003). Subcutaneous emphysema after robotic heart surgery occurs preferentially in patients with low body weight, low BMI, a small body surface area, and older age and is more common in robotic MVR than in robotic coronary artery bypass surgery. It leads to an increased need for thoracic imaging and additional chest tube insertion. Clinical outcomes are not affected.

In the era of minimally invasive surgery (MIS), parenchyma-preserving liver resections are gaining prominence with the potential to offer improved perioperative outcomes without compromising oncological safety. The surgeon learning curve remains challenging, and simulation plays a key role in surgical training. Existing simulation models can be limited by suboptimal fidelity and high cost. We describe a novel, reproducible, high-fidelity, low-cost liver metastases model using porcine livers from adult Landrace pigs, with porcine perinephric fat used to simulate subcapsular metastases. This model was then utilised in a training session for surgical trainees performing robotic parenchyma-preserving surgery (PPS) under the guidance of expert robotic surgeons, with feedback being recorded. Trainees rated the model highly on its fidelity to human liver simulation (median score 9), tissue handling (median score 8), and overall usefulness (median score 9). Tissue handling was felt to simulate in vivo liver resection closely, while suggestions for improvement included adding simulated blood flow. This is a novel, low-cost, high-fidelity simulation model of liver metastases with high acceptability to surgical trainees, which could be readily adopted by other training centres.

It was a systematic review and meta-analysis that aimed to compare the efficiency and safety of robot-assisted urological surgery using both the KangDuo and da Vinci robotic systems. The PubMed, Embase, and Cochrane Library databases were searched for all papers published through September 1, 2024. The focus was on English-language papers comparing the KangDuo surgical robot and the da Vinci system in urological procedures. The screening method focused on RCTs and cohort studies and followed strict criteria. Three cohort studies and two randomised controlled trials with 300 adult urological surgery patients met the inclusion criteria. These 150 patients were operated on with the KangDuo robotic system and 150 with the da Vinci system. The investigation showed that whereas KangDuo operations were slightly longer, intraoperative blood loss, hospital stay, and postoperative complication rates were similar. The KangDuo robotic system performs urological surgery as well as the da Vinci system, although it takes longer. Future large-scale multicenter randomized trials are recommended to gather further evidence and enhance clinical understanding.