1,721,111 research outputs found
The use of da Vinci Xi and the increased surgeon's experience could change the perspective over the cost-benefit ratio of robot-assisted surgery
No full textTo the Editor:
We read with great interest the article by Khorgami et al. entitled “The cost of robotics: an analysis of the added costs of robotic-assisted versus laparoscopic surgery using the National Inpatient Sample” [1] recently published on Surgical Endoscopy.
The introduction of robotic systems in surgery was intended to overcome the known limitations of conventional laparoscopic surgery, while preserving the advantages of the minimally invasive surgery [2], justifying the growing interest in robotic technology for abdominal surgery worldwide. However, the costs of robot-assisted surgery (RAS) still represent a critical issue for its widespread adoption.
The study of Khorgami et al. is a very well structured retrospective analysis of the 2012–2014 Healthcare Cost and Utilization Project-National Inpatient Sample which is the largest inpatient health care database in the United States, collecting data from more than 7 million hospital admissions annually. A total of 91,630 abdominal major and minor surgeries (87,965 laparoscopic, 3,665 robotic) were analyzed, including cholecystectomy, ventral hernia repair, right and left hemicolectomy, sigmoidectomy, abdominoperineal resection, and total abdominal hysterectomy. The average cost for the laparoscopic group was 4986 versus 5880 for the robotic cases (p < 0.001), suggesting that RAS is more costly when compared to conventional laparoscopic surgery. However, robotic total abdominal hysterectomy showed the lowest increased cost and was the only procedure to be performed more often robotically. This suggests that although RAS costs are higher, the difference may be offset with more routine performance of procedures using the robot.
Some recent published studies of our group on rectal surgery [3,4] support this theory, showing a significant decrease of RAS overall variable costs with surgeon’s experience. This means that a possible major bias of the current economic evaluations such as those of this article, unfavorable to RAS when compared to standard laparoscopy, is that they are referred mainly to results obtained by comparing expert laparoscopists with novice robotic surgeons.
A second possible bias, is that the study of Khorgami et al. refers to the years 2012-2014, when the new da Vinci Xi robotic platform was not available yet. Indeed, recent works have reported that the use of the new da Vinci Xi represents an improvement on its Si predecessor in robot-assisted colorectal resections, being associated with shorter operative time, reduced docking time and higher full robotic resection rates and significantly reducing RAS-associated costs [3-5].
In conclusion, the article by Khorgami et al. deals with a very interesting topic analyzing a huge sample size. However, the use of the new da Vinci Xi platform, as well as of new robots, by robotic surgeons with an adequate experience could nowadays change the perspective over the cost-benefit ratio of RAS
Response to the comment on "pattern of recurrence and survival after D2 right colectomy for cancer: is there place for a routine more extended lymphadenectomy?"
No full textNew perspectives about the role of robot-assisted surgery for the treatment of endometriosis
No full textWe read with great interest the recently published article by Comptour et al. entitled “Patient Quality of Life and Symptoms after Surgical Treatment for Endometriosis”.
Painful gynecological and digestive symptoms of endometriosis have been shown to severely affect the patients’ quality of life (QoL), and various studies have described the benefits of surgery in the treatment of endometriosis, particularly in its worst presentation, namely, Deep Infiltrating Endometriosis (DIE). Comptour et al. have designed a prospective and multicenter cohort study to assess the impact of surgical treatment of endometriosis on quality of life and pain, and their results seem to confirm these benefits
Contrast Enhanced Ultrasound in Detecting Biliary Complications After ABO-Incompatible Liver Transplantation
No full textComment on: ‘Money for nothing’. The role of robotic-assisted laparoscopy for the treatment of endometriosis
No full textTo the Editor:
We read with great interest the published article by Berlanda et al. entitled “Money for nothing”. The role of robotic-assisted laparoscopy for the treatment of endometriosis [1].
Deep infiltrating endometriosis (DIE) with colorectal involvement is one of the most aggressive forms of endometriosis. At present, a minimally invasive surgery (MIS) and in particular the direct manual laparoscopy (DML), is considered the gold standard for radical treatment of DIE with colorectal involvement, as it results in faster recovery, reduced in-hospital stay, improved cosmesis, and lower postoperative morbidity compared to laparotomy. Robot-assisted surgery (RAS), is a technological advancement of DML, introduced with the aim to overcome its kinematics limitations.
In recent years, the diffusion of the da Vinci System has created much enthusiasm has grown between surgeons of different specialties, with a constantly growing application of RAS, and several studies have been published to describe safety and efficacy of RAS, as well as to compare RAS to DML. In particular, colorectal surgeons and gynecologists have explored RAS and have also applied it to the treatment of DIE [2].
In the article, Berlanda et al. describe a very well structured critical review of the literature about the role of RAS for the treatment of endometriosis. In particular, they reported that RAS treatment of endometriosis did not provide clear benefits over standard laparoscopy, in the face of a longer operative time and higher costs. They, therefore, express concern for economic sustainability in the face of increasing use of the widely diffusion of da Vinci system, and they made conclusions against the use of robot for the treatment of DIE.
However, we have noticed that in all of the article the authors uses generically the terms of “robotic-assisted laparoscopy”, without specifying which system they refer to and in truth, the whole study is based on the da Vinci Si system, the most widespread version to date until recently. Indeed, only in the last 2–3 years, in many centers it has been gradually replaced by the most recent version, the da Vinci Xi. Therefore, we can agree with the conclusions reached by the authors only if applied to a specific robotic system, namely the da Vinci Si, but not if generalized to the broader concept of “RAS”.
In fact, recent works have shown that many of the conclusions reached to date, in the comparison between DML and RAS, unfavorable to the latter because of the longer operating times and higher costs, without clear evidence of clinical benefits, are referred to results obtained by comparing expert laparoscopists with novice robotic surgeons, using a now almost obsolete robotic system, the da Vinci Si.
Indeed, recently data published by our group on rectal resections performed with the two different da Vinci systems, showed that with the new robot, and with the increase of the surgeon’s experience, the results improve, and the costs are significantly reduced [3, 4, 5].
In conclusion, the article by Berlanda et al. deals with a very interesting topic using objective and critical methods. However, today the use of da Vinci Xi with case series being performed by expert robotic surgeons, and the use of new robotic system that will enter in the market, represents a totally different proposition from what is reported in this study, requiring careful objective re-evaluation of cost–benefit of RAS, also in the surgical treatment of DIE
Going Beyond Counting First Authors in Author Co-citation Analysis
Full text linkThe present study examines one of the fundamental aspects of author co-citation analysis (ACA) - the way co-citation
counts are defined. Co-citation counting provides the data on which all subsequent statistical analyses and mappings
are based, and we compare ACA results based on two different types of co-citation counting - the traditional type that
only counts the first one among a cited work's authors on the one hand and a non-traditional type that takes into
account the first 5 authors of a cited work on the other hand. Results indicate that the picture produced through this non-traditional author co-citation counting contains more coherent author groups and is therefore considerably clearer. However, this picture represents fewer specialties in the research field being studied than that produced through the traditional first-author co-citation counting when the same number of top-ranked authors is selected and analyzed. Reasons for these effects are discussed
HALS, EVAR and robot-assisted surgery as minimally invasive approaches for abdominal aneurysm treatment
No full textDear Editor, We read with great interest the article by Berchiolli et al. [1] entitled “Hand-assisted laparoscopic surgery versus endovascular repair in abdominal aortic aneurysm treatment”, recently published by Journal of Vascular Surgery. In last decade, we have seen a paradigm shift in aneurysm repair towards a minimally invasive approach, mainly related to the preeminence of endovascular aneurysm repair (EVAR). Actually, laparoscopy and robot-assisted surgery also have a role in this field. Many studies have also described the benefits of EVAR, considered one of the most important options, in the acute setting [2], with faster recovery and shorter hospitalization. However, the main drawback remains its long-term seal. In fact, despite the advent of a new model of vascular graft, more than 5% of EVAR patients require reintervention [3]. Another concern is the cumulative radiation and iodinated contrast exposure in patients undergoing EVAR. In this setting, laparoscopic surgery is an appealing alternative, because it represents a minimally invasive option with a potentially higher long-term success rate. One of the main criticisms of this approach is the learning curve, which can be particularly steep for vascular surgeons, who are not used to it. On the contrary, the hand-assisted laparoscopic surgery (HALS), thanks to the manual control of the sac during dissection and sutures, is associated with a higher level of safety and with a shorter learning curve, still maintaining the advantages of minimally invasive surgery [4]. HALS has been introduced for abdominal aortic aneurysm treatment in some centers [5], showing encouraging results and a lower risk of aneurysm-related reintervention if compared to EVAR. An important remark on this work [1] concerns costs. In fact, a preliminary cost analysis of the perioperative period has shown a lower cost of HALS compared to EVAR and this difference could be even greater if we consider the economic impact of a stricter follow-up, which is mandatory for patients underwent EVAR, and the possible costs related to the risk of reoperation, which is higher in the EVAR group. Another possible minimally invasive alternative for aneurysm repair is robot-assisted surgery (RAS). Indeed, the robotic assistance can be very useful in this field, overcoming the kinematics limitations of laparoscopy and resulting in a potential higher level of precision and control and in a shorter learning curve [6]. This is even more evident with the latest da Vinci Xi [7], which combines the functionality of a boom-mounted system with the flexibility of a mobile platform allowing the operating surgeon to quickly scan over a wider operative field. The scope can be placed on any of the 8-mm robotic trocar, improving versatility. RAS could have also a specific role in Type-II Endoleak, the most frequent complication after EVAR [8], allowing the operating surgeon the ligation of aortic collaterals responsible for endoleak inflow and outflow in an easier way with respect to laparoscopy and in a definitive manner with respect to endovascular embolization, which is the first-line treatment option, but still has high recurrence rates. The main issues about RAS remain those related to costs; however, recent articles have suggested an economic gain with increasing surgeon’s experience and with the use of da Vinci Xi [9, 10], and this could also finally open the way for RAS for these procedures. For these reasons, we believe that the diffusion of HALS and RAS between vascular surgeons should be encouraged. Since literature lacks prospective studies about their use in vascular surgery, it would be interesting to value on a larger scale the usefulness and the application of these two well-consolidated minimally invasive techniques also to the vascular field
Is there a role of robotic surgery in abdominal organs transplantations?
No full textAbdominal organs transplantations represent the only poten-tially curative treatment in several end stage-diseases, but despite the improvement of the surgical techniques and the overall good outcomes, the invasiveness of these procedures is still very high. Therefore, the possible application of mini-mally invasive surgery in this field would be of great interest.Until a few years ago this application was not even con-sidered because of the kinematic limitations of laparoscopy which makes very challenging to carry out the reconstruc-tive phases of the transplant. Instead, more recently, since the successful introduction of the da Vinci Surgical System, the possible application of robot-assisted Surgery (RAS) in organ transplantation has become a reality [1].Indeed, with RAS, several limitations of laparoscopic technique for minimally invasive surgical procedures have been overcome, particularly with its latest version, the da Vinci Xi, capable to ensure an easy docking, a wide range of motion with its small, thin arms, the ability to attach the endoscope to any arm, and a highly flexible access to differ-ent anatomical regions [2]. Thus, thanks to these features, the execution of vascular anastomoses has become feasible, offering a new impetus in proposing a minimally invasive approach to patients suitable for an abdominal solid organ transplantation.However, although the technical feasibility of RAS to certain abdominal transplantations procedures has been recently demonstrated by several groups [1], we think that its use in this field is still affected by some main limita-tions that prevent its wide diffusion. In fact, the first critical issue is related to the donor organ’s insertion and manipula-tion through a narrow incision, with the associated risk of organ damage and/or difficult positioning. Furthermore, this limitation together with the longer execution time of vascu-lar anastomoses, could negatively impact on the ischemia time, the reduction of which is instead crucial, especially nowadays that organs procurement from deceased marginal donors is becoming more and more frequent to shorten the continuously growing waiting lists [3, 4].For all these reasons, although dedicated clinical postop-erative follow-up strategies [5, 6] and optimized immuno-suppressant therapies [7, 8] have contributed today to very good outcomes in abdominal solid organs transplantations even with marginal donors, the reduction of operative time for the reconstructive phase is still a major critical factor, and can represent a major limitation for a wide application of RAS.Finally, the use of RAS for organ transplantations on a wider scale could clash with two other non-clinical funda-mental matters, such as the necessity of a continuous avail-ability of the robotic system for a non-elective surgery and the economical sustainability of this approach [9].In conclusion, we think that RAS in transplant surgery is an appealing and promising technique, and without any doubt it represents an open window out to the future, but today it is still far to become the new standard approach, particularly for deceased donor organs transplantation
- …
