By: Sijo Parekattil, M.D.
What is Robotic Assisted Microsurgery?
Robotic assisted surgery has had a tremendous impact in surgical procedures such as the removal of the prostate for prostate cancer and for kidney cancer surgery. The benefits for the patient are related to a possible quicker recovery and smaller incisions. Robotic assistance may aid surgeons in performing these otherwise complex procedures in a minimally invasive manner. Under the direction of Sijo J. Parekattil, M.D., the only dual fellowship trained robotic and microsurgery urology specialist in the country, a new robotic microsurgery collaborative program has been created between Winter Haven Hospital and the University of Florida. This robotics program has developed new robotic assisted microsurgical procedures to help in treating conditions such as male infertility and chronic testicular or groin pain. These new procedures utilize the robotic platform instead of a pure microsurgical platform to provide enhanced magnification, scaling of motion and elimination of tremor for extremely complex microsurgical procedures. This center is the leading program in the world performing such robotic assisted microsurgery – over 700 procedures have been performed so far (the largest experience of this kind in the world).
What kinds of treatment options are available with this new technology?
Some of the procedures being performed are:
- Robotic assisted microsurgery for vasectomy reversal and congenital obstruction repair (such as cystic fibrosis vasal obstruction)
- Robotic assisted microsurgical varicocelectomy for the treatment of varicoceles in men
- Robotic assisted microsurgical testicular sperm extraction (Robotic Micro TESE) to detect and collect sperm from the testicle in men who have no sperm in the ejaculate
- Chronic testicular and groin pain – novel robotic assisted microsurgical targeted neurolysis or denervation of the spermatic cord to treat this condition
How can surgeons be trained to acquire these new Robotic Microsurgery Skills?
This article is going to focus on some new research work at Winter Haven Hospital & the University of Florida on the development of two new training models for surgeons who would like to acquire robotic microsurgical skills.
a) A Novel Synthetic Vas Deferens Model for Microsurgical Training
Microsurgical vasectomy reversal is a technically challenging procedure. Our current training models for microsurgical skills training for this procedure include live rodent and cadaver vas deferens models – both of which are expensive and require appropriate training lab facilities. The goal of this study was to develop an inexpensive, easily accessible synthetic vas deferens (SVD) model for microsurgical skills training.
Methods: A synthetic vas deferens (SVD) model was developed based on an inexpensive hydrocarbon material (SynDaver Labs, Tampa) as shown in Figure 1. Mechanical tissue shear and puncture properties where modeled to mimic human vas deferens tissue. The shape, diameter and lumen size was based on 6 human vas deferens samples. The new model was then tested on 21 trainee microsurgeons during a hands-on microsurgical training lab. Measures recorded where ease of use, tactile similarity to human vas and suturing ability.
Results: Mean width and wall thickness for the human vas was 5.08mm and 1mm, respectively. For SVD, 5.08mm and 2mm, respectively. For shear (break point) testing, the mean break stress was 12.07psi for SVD and 12.16psi for human vas (statistically similar). For puncture testing (1mm blunt needle inserted into tissue at 50mm/min), the mean peak load for 7 SVD samples was 9.71N, and 14.53N for 6 human vas samples (p = 0.02). During the 21 microsurgeon trainee lab, all the surgeons reported ease of use, tactile sensation similar to human vas and ability to suture an anastomosis similar to human vas. There were 3 minor complaints: 1) lack of consistency of the vas lumen size along the length of the SVD in some samples, 2) diffusion of the microdots placed on the transected SVD surface (used during the microdot vasovasostomy technique), and 3) difficulty in securing the SVD to the vasovasostomy holder in some cases where the SVD outer lining was very smooth and slippery.
Conclusion: The preliminary results in the mechanical and clinical testing of the synthetic vas deferens model appear promising. Further refinements to the model have been made based on the above feedback. This model may provide a very cost-effective, portable alternative to our current microsurgical training models.
b) Robotic Assisted LEGO® construction as a model for Robotic Microsurgery Skills Training
The application of robotic assisted microsurgery has been expanding over the last few years. However, there are limited structured training protocols for robotic microsurgical skill development. The existing microsurgical training models (rodent and cadaver models) are also quite tedious and expensive. Our goal was to assess the use of robotic assisted Lego construction for robotic microsurgical skills training and compare it to our current standard.
Methods: 10 trainees (6 medical students and 4 urology residents) were enrolled in the study (all where robotic surgery naïve). The trainees where randomized into two arms: 1) a test group and 2) a control group. The test group performed 5 sessions: 1 robotic assisted microsurgical vasovasostomy on a biosynthetic vas deferens model (anastomosis with 4 double armed 10-0 nylon sutures using microdot technique) – this was the pre-training test procedure, 3 training sessions where the trainee built a 77 piece Empire State Building Lego® set to completion with robotic assistance using all 3 instrument arms, and then a final test session vasovasostomy on the vas deferens model. The control group also performed 5 sessions: they performed 5 repetitive robotic assisted vasovasostomy procedures on the vas deferens model – an initial pre-training test anastomosis, 3 training vasovasostomy sessions and then a final test anastomosis. The pre-training vasovasostomy was then compared to the post-training vasovasostomy for all trainees: duration, number of sutures used, suture breaks, needle bends, distance between suture placement and microdot where compared (a scoring methodology was developed).
Results: The mean pre-training vasovasostomy measures did not differ significantly between the Lego® and control arms. Mean duration of the anastomosis before and after training was 64.5min and 28.3min (Lego® test group); 88.5min and 34min (control group), respectively. Mean number of sutures used, needle bends and suture breaks significantly decreased after training in both arms. The mean quantitative scores of the first test anastomosis were 2 (Lego® group) and 0.5 (control group). These scores improved after training to 10.25 (Lego® group) and 5.5 (control group). The score improvement after training did not differ significantly between the Lego group and the control group (p = 0.25).
Conclusion: Although this is a small sample size, this preliminary study appears to indicate that robotic assisted Lego® construction may provide a comparable training model to develop robotic assisted microsurgical skills
Sijo J. Parekattil, MD, is Director of Urology & Robotic Surgery for Winter Haven Hospital and University of Flor- ida, Winter Haven, FL, and is an Assistant clinical profes- sor of Urology and an Adjunct professor of Bioengineering. He has dual fellowship training from the Cleveland Clinic Foundation, Cleveland in Laparoscopy/Robotic Surgery and Microsurgery and was an Electrical Engineer prior to his medical training and thus has interests in surgical techniques incorporating technology, robotics and micro- surgery. Dr. Parekattil also runs a dedicated Male Infertil- ity and Groin Pain/Testicular Pain Clinic at Winter Haven Hospital, Winter Haven (863-292-4652 or www.roboticin- fertility.com) As an infertility patient himself at one point, he is truly dedicated to these patients. He may also be con- tacted at firstname.lastname@example.org.