Computer-assisted surgery in children
Abstract: Although positive in terms of patient trauma and recovery time, minimally invasive surgery has several technical drawbacks compared with open surgery. The new da Vinci® Surgical System from Intuitive Surgical® offers technical innovations aiming at overcoming these drawbacks and at improving the surgeon’s operating skills, such as the improved 3-D vision, tremor reduction and flexible instruments with a more natural and intuitive range of motion. In this thesis, the computer-assisted surgical instruments, and their application in paediatric surgery and paediatric urology, were investigated. In a prospective study of the first six fundoplications using the da Vinci® Surgical System, retrospective data from the open surgical procedure and the conventional laparoscopic technique were used as controls. Computer-assisted laparoscopic surgery (CALS) was safe and feasible. The operating time for the computer-assisted procedure was longer than the open one, but comparable to the laparoscopic procedure, and the need for postoperative morphine analgesics and the length of hospital stay were reduced with the two minimally invasive methods. The short-term clinical outcome did not differ, the symptoms of gastroesophageal reflux disease disappeared in all the children. The costs for CALS were compared with the costs for open and laparoscopic surgery in children. The total costs of CAL fundoplication amounted to EUR 9584. The costs for laparoscopic and open fundoplication amounted to EUR 8982 and EUR 10521, respectively. The cost of the CALS instruments per procedure (EUR 2081) accounted for the extra expense compared with laparoscopy. The increased costs for CALS due to longer operating time, were offset by the shorter hospital stay compared with open surgery, 3.8 and 7.9 days, respectively. An experimental study of students with no prior surgical experience and divided by gender was performed to test the hypothesis that maiden users master surgical tasks more quickly with computer-assisted than with standard laparoscopic instruments. Each surgical task was performed four times with one of the techniques before changing to the other. Speed and accuracy were measured. A cross-over technique was used to eliminate gender bias and the experience gained from carrying out the first part of the study. The more advanced task of tying a knot was performed faster with the computer-assisted than with the laparoscopic technique. Shorter time was observed when the change was made from laparoscopy to the computer-assisted technique. Gender did not influence the results. The lack of tactile feedback in computer-assisted laparoscopy seemed to matter. A case-control study of ten consecutive children undergoing computer-assisted retroperitoneoscopic nephrectomy due to a non- or malfunctioning kidney was performed. This prospectively gathered consecutive group of children was compared with a retrospectively collected group of all other children who had undergone open nephrectomy for benign renal disease at our centre between 2005 and 2009. All nephrectomies were performed with the retroperitoneal approach. Endpoints of this study were safety, the operating time, the number of postoperative doses of morphine, the length of hospital stay and the number of complications. Four out of ten patients in the CALS group had a total operating time within the range of the operating time for an open procedure but it was longer for the CALS procedure. The number of postoperative doses of morphine did not differ, but the hospital stay was shorter for the CALS group. The patient benefit from CALS, in the form of low morbidity, improved cosmetics and shorter hospitalisation was associated with the minimally invasive approach. Whether computer-assistance leads to better long-term results and fewer postoperative complications is too early to determine. However, considering all the potential benefits of the CALS instruments, the future will favour its use in paediatric surgery.
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