ENGLISH

Robotic Surgery

By Farid Gharagozloo; Vipul R. Patel; Pier Cristoforo Giulianotti; Robert Poston; Rainer Gruessner; Mar

Book information

Publisher
Springer International Publishing
Year
2020
ISBN
3030535932, 9783030535933
Language
english
Format
PDF
Filesize
155 MB (162332943 bytes)
Edition
2
Pages
1599\1548
Time added
2021-03-31 03:52:02

Description

The first edition of Robotic Surgery was written only a decade after the introduction of robotic technology. It was the first comprehensive robotic surgery reference and represented the early pioneering look ahead to the future of surgery. Building upon its success, this successor edition serves as a complete multi-specialty sourcebook for robotic surgery. It seeks to explore an in-depth look into surgical robotics and remote technologies leading to the goal of achieving the benefits of traditional surgery with the least disruption to the normal functions of the human body. Written by experts in the field, chapters cover the fundamental principles of robotic surgery and provide clear instruction on their clinical application and long term results. Most notably, one chapter on “The Blueprint for the Establishment of a Successful Robotic Surgery Program: Lessons from Admiral Hymen R. Rickover and the Nuclear Navy” outlines the many valuable lessons from the transformative change which was brought about by the introduction of nuclear technology into the conventional navy with Safety as the singular goal of the change process. Robotics represents a monumental triumph of surgical technology. Undoubtedly, the safety of the patient will be the ultimate determinant of its success. The second edition of Robotic Surgery aims to erase the artificial boundaries of specialization based on regional anatomy and serves as a comprehensive multispecialty reference for all robot surgeons. It allows them to contemplate crossing boundaries which are historically defined by traditional open surgery. Foreword Preface Acknowledgement Contents Contributors Part I: Robotic Surgery: Overview 1: The Journey from Video Laparoscopy to Robotic and Digital Surgery 1.1 Visibility and Tangibility 1.2 Paradigm Shift 1.3 Before Video Endoscopy 1.4 Gynecologic Surgery 1.5 The Video Revolution 1.6 Changing the Perspective 1.7 The Role of Endometriosis in Changing Surgery 1.8 Laparoscopy Begets Industry 1.9 Overcoming the Test of Time 1.10 Introducing the Telepresence Platform 1.11 Conclusion References 2: The Origins of Minimally Invasive and Robotic Surgery and Their Impact on Surgical Practice: A Sociological, Technological History 2.1 Preface 2.2 Past Is Prologue 2.3 Pre-history 2.4 Antiquity 2.5 The Industrial Revolution 2.6 The Endoscope as a Basic Tool 2.7 The Surgeons Claim Minimally Invasive Surgery 2.8 The MediCal Meeting and The New Technology 2.9 The Revolution 2.10 The Quest for a Surgical Robot 2.11 Arrival of Surgical Robots 2.12 The Impact on Surgical Practice 2.13 Advantages of the Technology 2.14 Advantages to Operator 2.15 Advantages Over Laparoscopic Surgery in General 2.16 Disadvantages 2.17 Quality Urology 2.18 Quality Gynecology 2.19 Quantity 2.20 Surgical Education/Training 2.21 Cost 2.22 Research 2.23 The Societies 2.24 Future 2.25 FINE References 3: History of Robotic Surgery 3.1 Background 3.1.1 Video-Endoscopic Surgery 3.2 Robotics in Medicine 3.2.1 PUMA (Programmable Universal Manipulation Arm) 560 3.2.2 PROBOT 3.2.3 ROBODOC 3.2.4 Aesop 3.2.5 Zeus 3.2.6 da Vinci References 4: Blueprint for the Establishment of a Successful Robotic Surgery Program: Lessons from Admiral Hyman R. Rickover and the Nuclear Navy 4.1 Introduction 4.2 Varying Views of Robotic Surgery 4.2.1 Robotic Surgery as Viewed by the Business Community 4.2.2 Robotic Surgery as Reported in the Media and Perceived by the Public 4.2.3 Robotic Surgery as Perceived by the Surgeons 4.3 The Rest of the Story: Concepts of Change Culture and Disruptive Innovation 4.3.1 Changing Cultures 4.3.2 Disruptive Innovation 4.4 Lessons About Organizational Change and Implantation of Disruptive Innovation from the Nuclear Navy 4.4.1 Hyman G. Rickover 4.4.2 Why Is Rickover Important? 4.4.2.1 Planning for Success 4.4.2.2 Details, Details, Details 4.4.2.3 Education 4.4.2.4 Responsibility and Owning the Problem 4.4.3 Changing to a Culture That Strives for Greatness 4.4.3.1 Disciplined People 4.4.3.2 Disciplined Thought 4.4.3.3 Disciplined Action 4.4.4 Culture of Greatness in the Operating Room 4.4.5 The Culture of Medicine Through Changing Medical Education from Emphasis on Science to Emphasis on the Patient 4.5 How Did This Situation Arise and What Can Be Done to Save Medicine in the Twenty-First Century? 4.5.1 Twentieth-Century Medical Education: The First Part of the Story 4.5.2 Twentieth-Century Medical Education: The Rest of the Story 4.5.3 Medical Education in the Twenty-First Century 4.6 In Summary References 5: Validating Robotic Surgery Curricula 5.1 The Rationale Behind the Need for Validated Robotic Surgery Training Curricula 5.2 What Does a Proper Robotic Training Curriculum Look Like? 5.3 How to Validate a Robotic Surgery Training Curriculum 5.4 Robotic Surgery Training: Virtual Reality Robotic Surgery Simulators 5.5 Training Curricula in Robotic Surgery 5.5.1 The European Association of Urology Robotic Training Curriculum 5.5.2 Fundamental Skills of Robotic Surgery (FSRS) 5.5.3 Proficiency-Based Robotic Curriculum 5.5.4 Basic Skills Training Curriculum (BSTC) 5.5.5 Society of European Robotic Gynaecological Surgery (SERGS) Curriculum 5.5.6 “Western Protocol” Cardiac Surgery Virtual Reality Curriculum 5.6 Assessment Tools to Evaluate Performance of Robotic Surgery Trainees 5.6.1 Global Assessment Tools 5.6.2 Procedure-Specific Assessment Tools 5.6.3 Automated Assessment Tools 5.6.4 Nontechnical Skills (NTS) Assessments 5.7 Conclusions References 6: Defining and Validating Non-technical Skills Training in Robotics 6.1 Introduction 6.2 Components of Non-technical Skills 6.3 Training Non-technical Skills 6.3.1 Didactic Teaching 6.3.2 Simulation-Based Training 6.3.3 Non-technical Skills Curricula 6.4 Assessment of Non-technical Skills 6.5 The Future of Non-technical Skills in Robotics 6.5.1 Individual Non-technical Skills Components Training and Assessment 6.5.2 Cognitive Training and Assessment 6.6 Conclusion References 7: Secrets of the Robotic Dance (The World’s Busiest Surgical Robot) 7.1 Introduction 7.2 Operating Room Costs 7.3 Robotic Dance Development 7.4 The Human Factor 7.5 Conclusion References 8: Credentialing and Privileging for Robotic Surgery in the United States 8.1 Introduction 8.2 Residents Completing Training 8.3 Experienced Robotic Surgeon Moving to a New Institution 8.4 Experienced Surgeon Wishing to Incorporate Robotic Surgery in Practice 8.5 Maintenance of Robotic Privileges 8.6 Deficiencies in Present Privileging Process for Robotic Surgery 8.7 Institute for Surgical Excellence’s Consensus Conference on Robotic Surgery Credentialing 8.8 The Role of Simulation-Based Training in Robotic Privileging 8.9 Robotic Team Training 8.10 Conclusion References 9: The Current State of Robotic Education 9.1 Introduction 9.1.1 History of FLS 9.1.2 History of FRS 9.1.2.1 FRS Methodology 9.1.2.2 FRS Results 9.2 Current State of Robotic Training During Residency 9.2.1 Graduate Medical Education Standardized Training Curriculum 9.2.1.1 Urology 9.2.1.2 Gynecology 9.2.1.3 General Surgery 9.2.1.4 Thoracic Surgery 9.2.2 Industry Training 9.2.3 Third-Party Training Curriculum 9.2.4 Resident Training Recommendations 9.3 Training Beyond Residency 9.3.1 Current Continuing Medical Education Robotic Training Courses 9.3.2 Basic Robotic Surgical Training 9.3.3 Advance Robotic Surgical Training Courses 9.3.4 Current Training Tools Used for Robotic Training 9.3.4.1 Virtual Reality Robotic Surgical Simulators 9.3.4.2 Robotic Dry Lab Trainers 9.3.4.3 Wet Lab Training 9.3.4.4 Current Assessments 9.4 Conclusion References 10: Real Tissue Robotic Simulation: The KindHeart Simulators 10.1 Introduction 10.2 Thoracic Surgery Simulator 10.3 Real Tissue Skills Platform 10.4 Abdominal Hernia Simulator 10.5 Colon Resection Simulator 10.6 Bariatric and Foregut Simulator 10.7 Pelvic Surgery Simulator Video Legends Reference 11: The Institute for Surgical Excellence: Its Role in Standardization of Training and Credentialing in Robotic Surgery 11.1 Introduction 11.2 Fundamentals of Robotic Surgery (FRS) Consensus Conferences 11.2.1 FRS Outcome Measures Consensus Conference 11.2.2 FRS Curriculum Planning Consensus Conference 11.2.3 FRS Curriculum and Simulation Development Consensus Conference 11.2.4 Consensus Conference for the FRS Curriculum Effectiveness Evaluation Study Design 11.2.5 RTN Consensus Conference 11.2.6 Specialty-Specific Curricula Consensus Conferences—Gynecology 11.2.7 Specialty-Specific Curricula Consensus Conferences—Thoracic Surgery 11.2.8 Train-the-Trainer Consensus Conference—Curriculum Development 11.2.8.1 Category 1: Consensus on Terminology 11.2.8.2 Category 2: Prerequisites for TTT Course Selection and TTT Qualifications 11.2.8.3 Category 3: Objectives and Focus of a TTT Course 11.2.8.4 Category 4: Pre-course Considerations 11.2.8.5 Category 5: Theory and Course Content 11.2.8.6 Category 6: Measuring Outcomes 11.2.9 Train-the-Trainer Consensus Conference—Teaching to Train and Assess Regarding Errors 11.2.10 Credentialing Consensus Conference 11.2.11 Registry Consensus Conference 11.3 Closing Remarks References 12: Opportunity Cost Analysis of Robotic Surgery 12.1 Introduction 12.2 Value Forgone by a Program Choosing Not to do Robotics 12.2.1 Robotics Reduces the Risk of Postoperative Complications 12.2.2 Robotics Reduces Never Events (i.e., Mediastinitis) Compared to Sternotomy 12.2.3 Robotics Improves the Quality Rating Leading to a Medicare Bonus Payment 12.2.4 Robotics Uses Bottleneck Resources More Efficiently 12.2.5 Increased Case Volume 12.2.6 Improved Hospital Reimbursement 12.2.7 Higher Levels of Patient Satisfaction 12.2.8 Better Performance in “Bundled Payment” for Care 12.3 Value of Avoiding Robotics 12.3.1 A Full Sternotomy Minimizes Perceptions of Poor Safety 12.3.2 There Is No Learning Curve for Open Surgery 12.3.3 Open Surgery Avoids the Need for Start-Up Costs 12.4 Factors Irrelevant to the Opportunity Costs of Robotics 12.4.1 Costs of Poor Team Morale 12.4.2 Capital Costs of the Robot 12.5 Summary of Analysis 12.6 Robotic Costs: Perception Versus Reality 12.7 Conclusions References 13: Political Aspects of Robotic Surgery 13.1 Introduction 13.2 Three Phases of a Robotic Program 13.2.1 Hype Phase 13.2.2 Trough of Disillusionment 13.2.3 Establishing a New Normal 13.3 Using Politics to Make Robotic Surgery Sustainable 13.3.1 Avoid Hype 13.4 Create a High-Performing Team 13.4.1 Improve Open and Honest Communication 13.4.2 Develop a Strategy for Late Laggards 13.4.3 Mitigate Disillusionment 13.4.4 Choose a Hospital That Can Support Innovation References 14: Achieving Financial Optimization of a da Vinci Robotic Program While Achieving Best Clinical Outcomes 14.1 Introduction 14.2 Creating a Robotic Program 14.3 From Program Launch to Best Practice: The Path to Maturity 14.4 Appropriate Robotic Patient Selection 14.5 Cases Complexity Designations 14.6 Stumbling Blocks: Defining the Problems 14.7 Data as the Critical Denominator 14.8 Data Management Must Include Powerful Analytics 14.9 Program Optimization: Other Key Factors 14.10 The Stages of Program Maturity 14.11 Management of the Surgeon Learning Curve 14.12 Standardized Cost Accounting Methods 14.13 Summary: The Key Steps to Robotic Program Optimization References 15: The Senhance® Surgical System 15.1 Overview of the Senhance Surgical System 15.2 History of Senhance Surgical System 15.3 System Components and Architecture 15.3.1 Manipulator Arms 15.3.2 Surgeon Console 15.3.3 Instrumentation 15.3.4 Open-Source Design Architecture 15.4 Regulatory Status 15.5 Summary of Clinical Experience 15.6 Conclusion References 16: Humanizing the Robot: Medicaroid’s Vision for the Future of Robotic Surgery 16.1 Introduction 16.2 History of Medicaroid 16.3 Medicaroid’s Robotic Operating Table 16.4 Medicaroid’s Robotic-Assisted Surgical System 16.5 Summary 17: Mazor Core Robots in Spine Surgery 17.1 Introduction 17.1.1 Implant Placement in Spinal Surgery 17.2 Spinal Instrumentation with Mazor Core Systems 17.2.1 Preoperative Planning 17.2.2 Intraoperative Setup 17.2.3 Intraoperative Guidance 17.3 Advantages of Mazor Core Systems 17.4 Clinical Evidence 17.5 Screw Placement Accuracy 17.6 Complication and Revision Rate 17.7 Intraoperative Radiation 17.8 Patient-Reported Outcomes 17.9 Learning Curve 17.10 Surgical Efficiency 17.11 System Limitations 17.12 Summary and Future Directions References 18: Intelligence and Autonomy in Future Robotic Surgery 18.1 What Does Future Surgery Look Like with Intelligent Collaborative Autonomy? 18.2 What Is the Critical Unmet Need for Intelligence and Autonomy in Surgery? 18.3 Current Applications of Intelligence and Autonomy in Hard and Soft Tissue Surgery 18.4 Current State of Technologies in Vision, Intelligence, and Dexterity for Complex Soft Tissue Surgery 18.4.1 Computer Vision 18.4.2 Intelligence 18.4.3 Dexterity 18.5 When Will Intelligence and Autonomy in Surgery Become a Standard Practice? 18.6 Future References 19: Intellectual Property Considerations and Patent Protection: A Surgical Roadmap 19.1 Introduction 19.1.1 What Is a Patent? 19.1.2 Getting a Patent 19.1.3 Patent as an Asset 19.2 What Makes a Patent Valuable? 19.2.1 The Enforcement Regime 19.2.2 Proper Drafting 19.2.3 Demand for Products and Competitive Landscape 19.3 Medical Practitioner Exception 19.4 Robotic Surgery Patent Landscape and Prospects 19.4.1 Early Patents in Robotic Surgery 19.4.2 Current Patent Landscape 19.5 Future Developments 19.6 Concluding Remarks References 20: The Internet of Skills: How 5G-Synchronized Reality Is Transforming Robotic Surgery 20.1 Introduction 20.2 History and Guiding Principles 20.2.1 Inspiration Behind the Internet of Skills 20.2.2 Human in the Loop 20.2.3 5G and Synchronized Reality 20.3 Technology Challenges 20.3.1 Challenges in Latency 20.3.2 Challenges in Artificial Intelligence 20.3.3 Challenges in Robotics 20.4 Application to Robotic Surgery 20.4.1 Virtualized Operating Theatre 20.4.2 “Hospital on Wheels” 20.4.3 Training of Medical Students 20.5 Current Trials and Future Work 20.5.1 Early Pioneering Milestones 20.5.2 Modern Demonstrations and Trials 20.5.3 Future Work and Conclusions References 21: Augmented Surgery: An Inevitable Step in the Progress of Minimally Invasive Surgery 21.1 Introduction 21.2 Visible Patient: The Preoperative Patient See-through 21.3 Augmented Reality: The Intraoperative Surgeon GPS 21.4 Conclusions References 22: Telementoring for Minimally Invasive Surgery 22.1 Introduction 22.2 Background 22.3 Infrastructure 22.4 Verbal Guidance 22.5 Guidance with Telestration 22.5.1 2D Telestration 22.5.2 3D Telestration 22.6 Guidance with Tele-Assist 22.7 Challenges to Adopting Surgical Telementoring 22.7.1 Safety Considerations 22.7.2 Legal Considerations 22.7.3 Financial and Economic Considerations 22.8 Discussion 22.9 Conclusions References 23: Automation and Autonomy in Robotic Surgery 23.1 Introduction 23.2 Basic Concepts and Terminology 23.3 Automation and Autonomy 23.4 Automation in Robotic Surgery 23.5 Autonomy in Robotic Surgery 23.5.1 Task Description 23.5.2 Knowledge Representation 23.5.3 Task Structure 23.5.4 Parameter and Variable Values 23.5.5 Sensor Identification and Data Processing 23.5.6 Semantic Reasoning 23.5.7 Control Architecture 23.5.8 Human Interface 23.5.9 Formal Verification 23.5.10 Lesson Learned from the I-SUR Project 23.6 Current Steps in the Design of an Autonomous Surgical Robot 23.6.1 Methods of Knowledge Representations 23.7 Conclusions References 24: Will Hydrogel Models Fabricated Using 3D Printing Technology Replace Cadavers as the Ideal Simulation Platform for Robotic Surgery Training? 24.1 Introduction 24.2 Methods 24.2.1 Construction of the Kidney Phantoms 24.2.2 Validation of Model’s Mechanical Properties 24.2.2.1 Mechanical Validation 24.2.2.2 Uniaxial Compression Testing 24.2.2.3 Suture Pull Through Test 24.2.3 Determining the Model’s Anatomical Accuracy 24.2.3.1 Development of Procedural Simulation Platform 24.2.3.2 Validation of Procedural Simulation Platform 24.3 Analysis and Results 24.3.1 Mechanical Testing 24.3.2 Anatomical Verification 24.3.3 Model Validity 24.4 Discussion 24.5 Conclusions References 25: Robotic Surgery: The Future as I See It 25.1 Introduction 25.2 Current and Preclinical Robotic Surgical Platforms 25.2.1 Da Vinci, Intuitive Surgical (Sunnyvale, USA) 25.2.2 Senhance, TransEnterix (Morrisvale, USA) 25.2.3 Revo-i, MeereCompany (Hwasong, Korea) 25.2.4 Versius, CMR (Cambridge, UK) 25.3 Limitations of Current Platform and Potential Improvements 25.4 Surgeon Console 25.5 Patient Cart/Gantry 25.6 Robotic Arms 25.7 Surgical Access 25.8 Democratising Surgery 25.9 Future Directions in Training and Simulation 25.9.1 Rapid Prototyping – 3D Printing 25.9.2 Virtual Reality 25.9.3 Nontechnical Skills in Simulation 25.9.4 Training Delivery 25.10 Artificial Technology 25.10.1 Machine Learning 25.10.2 Autonomous Surgery 25.10.3 Limitations of AI References Part II: Thoracic Section 26: The Basics of Starting a Robotic Thoracic Surgery Program 26.1 Introduction 26.2 How to Start 26.3 Lessons Learned References 27: Instrumentation, Energy Devices, Staplers 27.1 Introduction 27.2 Instrumentation 27.3 Energy Devices 27.4 Staplers 27.5 Future of Robotic Surgery 27.6 Conclusion References 28: Robotic Lobectomy 28.1 Introduction 28.2 Screening 28.2.1 Chest Radiographs 28.2.2 Chest CT Scans 28.3 Historical Perspective 28.4 Definition of VATS Lobectomy 28.4.1 Mini-Thoracotomy with Video Assistance 28.4.2 Simultaneously Stapled Lobectomy 28.4.3 Individual Ligation Lobectomy with a Utility Thoracotomy 28.4.4 Needlescopic VATS 28.4.5 Two-Port VATS Lobectomy 28.4.6 Uniportal VATS Lobectomy 28.4.6.1 Risk of Life-Threatening Bleeding 28.4.6.2 Seeding of the Incision Sites 28.5 Benefits of Minimally Invasive Lobectomy 28.5.1 Reduction of Inflammatory Response 28.5.2 Decreased Postoperative Pain 28.5.3 Preservation of Pulmonary Function 28.5.4 Return to Normal Activity 28.5.5 Survival 28.6 The Development of VATS Lobectomy at Our Institution 28.6.1 Phase I: Video-Assisted Small-Incision Lobectomy 28.6.2 Phase II: Simultaneously Stapled Thoracoscopic Lobectomy (SSL) 28.6.3 Phase III: VATS Individual Ligation Lobectomy 28.6.3.1 Anatomy 28.6.3.2 Visualization 28.6.3.3 Lack of Tactile Input 28.6.3.4 Endosuturing 28.6.3.5 Stapling Devices 28.6.3.6 Specimen Retrieval 28.6.3.7 Aerostasis 28.6.3.8 Analgesia 28.6.4 Phase III Clinical Experience 28.6.4.1 VATS Individual Ligation Lobectomy (ILL) 28.6.5 Phase IV: Robotic Completely Endoscopic Lobectomy (Hybrid Robotic Dissection with VATS Bronchovascular Division) 28.7 Operative Technique 28.7.1 Anesthesia 28.7.2 Patient Positioning 28.7.3 Stage I: Routine VATS 28.7.4 Stage II: Robotic Mediastinal Dissection 28.7.5 Stage III: Robotic Dissection of the Pulmoary Artery Branches in the Fissure 28.7.6 Stage IV: Anterior Hilar Dissection 28.7.7 Phase V: Division of the Vessels and the Bronchus 28.7.7.1 Results 28.7.7.2 Learning Curve of Robotic Lobectomy 28.7.8 Phase V: Robotic Port-Based Lobectomy 28.7.8.1 Right-Sided Lobectomy 28.7.8.2 Right Upper Lobectomy 28.7.8.3 Right Middle Lobectomy 28.7.8.4 Right Lower Lobectomy 28.7.8.5 Left-Sided Lobectomy 28.7.8.6 Left Upper Lobectomy 28.7.8.7 Left Lower Lobectomy 28.8 Control of Major Vascular Injury 28.9 Results References 29: Robotic Right Upper Lobectomy with Mediastinal Lymph Node Dissection 29.1 Introduction 29.2 Preoperative Planning 29.3 Operative Setup 29.4 Port Placement and Robot Setup 29.5 Fissure Dissection 29.6 Posterior Hilar Dissection and Division of the Posterior Fissure 29.7 Anterior Hilar Dissection and Division of the Minor Fissure 29.8 Superior Hilar Dissection 29.9 Division of Vascular Structures and Bronchus 29.10 Specimen Removal 29.11 Superior Mediastinal Lymph Node Dissection 29.12 Inferior Mediastinal Lymph Node Dissection (Including Subcarinal) 29.13 Final Steps 29.14 Additional Tips and Special Circumstances 29.15 Conclusions References 30: Robotic Right Lower Lobe Lobectomy 30.1 Introduction 30.2 Indications for Robotic Right Lower Lobectomy 30.3 Conduct of Operation 30.4 Port Placement for Xi and Si Robots 30.5 Right Lower Lobe Lobectomy 30.6 Alternative Techniques for Right Lower Lobe Lobectomy 30.7 Postoperative Management After Robotic Lobectomy 30.8 Summary Steps of Robotic Right Lower Lobectomy Appendix References 31: Mediastinal Lymph Node Dissection and Approach to the Fissures 31.1 Introduction 31.2 Pre-operative Assessment 31.3 Operative Technique 31.4 Right-Sided Dissection 31.4.1 Right Paratracheal Station 4R 31.4.2 Subcarinal Station 7 31.4.3 Pulmonary Ligament Station 9 31.4.4 Interlobar Lymph Node Station 11R “Sump” 31.5 Left-Sided Dissection 31.5.1 Subcarinal Station 7 31.5.2 Subaortic and Paraaortic Stations 5 & 6 31.5.3 Interlobar Lymph Node (11L “Sump”) 31.6 Fissure Completion Approaches 31.6.1 Right and Left Major Fissures 31.6.2 Right Minor Fissure 31.7 Fissureless Approaches 31.8 Technical Considerations 31.9 Complications 31.10 Conclusion References 32: Robotic Surgery of the Mediastinum 32.1 Introduction 32.2 Anatomy 32.3 Pathology 32.4 Clinical Presentation 32.5 Traditional Surgical Access to the Mediastinum 32.5.1 Prevascular Zone 32.5.2 Retrovascular, Pretracheal Zone 32.5.3 Posterior, Prevertebral Zone 32.6 Robotic Surgical Approach 32.6.1 General Principles 32.6.2 Phase I 32.6.3 8065.3 Phase II 32.7 Anterior Compartment or Anterior Mediastinum 32.7.1 Thymus 32.7.1.1 Thymic Tumors 32.7.1.2 Thymectomy for Myasthenia Gravis 32.7.2 Lymphoma 32.7.3 Parathyroid Adenoma 32.7.4 Germ Cell Tumors 32.8 Visceral Compartment or Middle Mediastinum 32.8.1 Lymphadenectomy 32.8.2 Bronchogenic Cysts 32.8.3 Pericardial Cysts 32.9 Posterior Compartment, Posterior Mediastinum, and Paravertebral Sulcs 32.10 Our Experience with Robotic Surgery for the Mediastinum 32.11 Conclusion Video Legends References 33: Robotic Extended Thymectomy 33.1 Introduction 33.2 Patient Selection 33.3 Preoperative Preparation 33.4 Positioning 33.5 Surgical Principles 33.6 Surgical Procedure 33.7 Postoperative Care 33.8 Limitations of Robotic Extended Thymectomy 33.9 Evidence in the Literature 33.10 Controversies 33.11 Summary References 34: The Robotic Approach to Intrathoracic Goiters 34.1 Introduction 34.2 Clinical Findings 34.3 Preoperative Testing 34.4 Treatment—Indications for Surgery 34.5 Surgical Technique 34.6 Tips and Pitfalls 34.7 Comments 34.8 Conclusion References 35: Robotic Anatomic Pulmonary Segmentectomy 35.1 Introduction 35.2 Historic Background 35.3 Embryology and Anatomy of Bronchopulmonary Segments 35.3.1 Right Bronchopulmonary Segments 35.3.2 Left Bronchopulmonary Segments 35.4 Technique of Robotic Segmentectomy 35.4.1 Port Placement 35.5 Right Lung Anatomic Segmentectomy 35.5.1 Port Placement with Si Robot 35.5.2 Port Placement with Xi Robot 35.5.3 Right Upper Lobe Anatomic Apical Segmentectomy (S1) 35.5.4 Right Upper Lobe Anatomic Posterior Segmentectomy (S2) 35.5.5 Right Upper Lobe Anatomic Anterior Segmentectomy (S3) 35.5.6 Right Middle Lobe Bisegmentectomy (S4, S5) = Right Middle Lobectomy 35.5.7 Right Lower Lobe Anatomic Superior Segmentectomy (S6) 35.6 Left Lung Anatomic Segmentectomy 35.6.1 Port Placement 35.6.2 Left Upper Lobe Anterior Anatomic Segmentectomy (S3) 35.6.3 Left Upper Lobe Apical and Posterior Anatomic Segmentectomy (S1, S2) 35.6.4 Left Upper Lobe Lingulectomy, Anatomic Segmentectomy (S4, S5) 35.6.5 Robotic Left Lower Lobe Anatomic Superior Segmentectomy (S6) 35.6.6 Robotic Left Lower Lobe Anatomic Basal Segmentectomy (S7–10) 35.7 Control of Major Vascular Injury 35.7.1 Prevention 35.7.2 Preparedness 35.7.3 Poise 35.7.4 Pressure 35.7.5 Proximal Control 35.8 Results References 36: Robotic Upper Lobe Pulmonary Segmentectomy 36.1 Introduction 36.1.1 Techniques of Robotic Upper Lobe Segmentectomies 36.2 Steps of the Procedure 36.2.1 Port Placement for Robotic Upper Lobe Segmentectomy 36.2.2 Right Upper Lobe Apical Segmentectomy (S1) 36.2.3 Right Upper Lobe Posterior Segmentectomy (S2) 36.2.4 Right Upper Lobe Anterior Segmentectomy (S3) 36.2.5 Left Upper Lobe Upper Division Segmentectomy (S1 + S2 + S3) 36.2.6 Lingular Segmentectomy (S4 + S5) References 37: Robotic Segmentectomy: Lower Lobes 37.1 Introduction 37.2 Surgical Indications for Segmentectomy 37.3 Pre-operative Planning 37.4 Operative Setup and General Aspects 37.5 Superior Segmentectomy (S6) 37.6 Basilar Segmentectomy (S7–10) 37.7 Individual Basilar Segments (S7, S8, S9, S10, or Combinations) 37.7.1 Medial Basilar (S7) Segmentectomy 37.7.2 Anterior Basilar (S8) Segmentectomy 37.7.3 Lateral and Posterior (S9 and S10) Segmentectomies 37.8 Results 37.9 Summary References 38: Hemorrhage Management During Robotic Surgery 38.1 Introduction 38.2 Robotic Pulmonary Resection: Risks and Tips 38.2.1 Poise 38.2.2 Pressure 38.2.3 PRBCs (Packed Red Blood Cells) 38.2.4 Partner 38.2.5 Proximal Control 38.2.6 Preparation, Practice, and Protocols 38.2.7 Prayers 38.3 Our Results 38.4 Conclusion Video Legends References 39: Robotic Wedge, Apical Pleural Flap, and Pleurodesis 39.1 Introduction 39.2 Approaches 39.3 Indications 39.4 Technique 39.5 Conclusions Reference 40: Robotic Pulmonary Decortication 40.1 Introduction 40.2 Approaches 40.3 Indications 40.4 Technique 40.5 Conclusions Reference 41: Robotic Surgery for Thoracic Outlet Syndrome 41.1 Historical Background 41.1.1 Cervical Ribs: Subclavian Artery Compression and Aneurysm 41.1.2 Cervical Ribs: Subclavian Artery Thrombosis and Stroke 41.1.3 Cervical Ribs: Compression of the Brachial Plexus 41.1.4 Cervical Ribs: Anterior Scalene Muscle 41.1.5 Cervical Ribs: Erroneous Association with Subclavian Vein Thrombosis 41.1.6 Cervical Rib Syndrome without a Cervical Rib 41.1.7 Concept of “Thoracic Outlet Syndrome” 41.2 History of Terms Used to Describe Upper Extremity Neurovascular Symptoms 41.2.1 Cervical Rib Syndrome 41.2.2 Brachial Compression Neuritis 41.2.3 Scalenus Anticus Syndrome (Naffziger Syndrome) 41.2.4 Costoclavicular Syndrome/Costoclavicular Compression Syndrome 41.2.5 Hyperabduction Syndrome/Wright Syndrome 41.2.6 Brachiocephalic Syndrome/Brachiocephalic Vascular Syndrome 41.2.7 Nocturnal Paresthetic Brachialgia/Brachialgia Statica Paresthetica 41.2.8 Paget–Schroetter Syndrome/Effort Thrombosis of the Subclavian Vein/ 41.2.9 Cervicobrachial Syndrome 41.2.10 First Thoracic Rib Syndrome/Superior Outlet Syndrome/Fractured Clavicle-Rib Syndrome/Cervical Rib and Band Syndrome 41.2.11 Thoracic Inlet Syndrome 41.2.12 Pectoralis Minor Syndrome 41.2.13 Cervicodorsal Syndrome 41.2.14 Cervicoaxillary Syndrome 41.2.15 Thoracic Outlet Syndrome/Thoracic Outlet Compression Syndrome 41.3 Cervical Rib Syndrome 41.3.1 Neurologic Symptoms 41.3.2 Vascular Symptoms 41.4 Thoracic Outlet Syndrome (TOS) 41.4.1 Conventional Thinking about TOS 41.4.2 Etiology of TOS 41.5 Diagnosis of TOS 41.5.1 Physical Examination 41.5.1.1 Adson’s Test 41.5.1.2 Wright’s Test 41.5.1.3 Roos (East) Test 41.5.1.4 Elvey (ULTT) Test 41.5.2 Diagnostic Tests 41.5.2.1 Imaging 41.5.2.2 Nerve Conduction and EMG 41.5.2.3 Anterior Scalene Block 41.6 Treatment 41.7 Pathogenesis of Paget–Schroetter Syndrome 41.8 Pathogenesis of Neurogenic TOS 41.9 Rethinking “TOS” 41.9.1 Cervical Rib Disease 41.9.2 Thoracic Outlet Disease or “Subclavian Vein Compression Syndrome” 41.10 Robotic First Rib Resection 41.11 Surgical Technique 41.11.3 Phase I – VATS Setup 41.11.4 Phase II – Robot Positioning and Robotic Dissection of the First Rib 41.11.5 Phase III – Division of the First Rib Using VATS Instruments 41.11.6 Phase IV – Robotic Dissection of the First Rib and Disarticulation of the Costo-Sternal Joint 41.11.7 Phase V – Analgesia and Chest Closure 41.12 Results 41.13 Conclusion Video Legends References 42: Robotic Diaphragmatic Plication 42.1 Introduction 42.2 Pathogenesis 42.3 Diagnosis 42.4 Non-operative Treatment 42.5 Operative Repair 42.6 Technique 42.7 Outcomes Video Legend References 43: Robotic Selective Thoracic Sympathectomy for Hyperhidrosis 43.1 Historical Background 43.2 Anatomy and Physiology of the Sympathetic Chain 43.3 Indications for Sympathectomy 43.3.1 Conservative Management 43.3.2 Alternative Surgical Therapies 43.3.3 Dorsal Thoracic Sympathectomy 43.3.3.1 Posterior Thoracic Approach 43.3.3.2 Cervical Supraclavicular Approach 43.3.3.3 Transthoracic Approach 43.3.3.4 Transaxillary Approach 43.3.3.5 Thoracoscopic Approach 43.4 Extent of Sympathectomy 43.5 Robotic Selective Dorsal Sympathectomy 43.5.1 Operative Technique 43.5.2 Results of Staged Bilateral Selective Sympathectomy for Upper Extremity Hyperhidrosis 43.5.2.1 Data Analysis 43.5.2.2 Results Video Legend References 44: Pain Control Following Robotic Thoracic Surgery 44.1 Introduction 44.2 Pathophysiology of Pain 44.3 Pain After Robotic Thoracic Surgery 44.4 Pain Management 44.4.1 Options for Postoperative Pain Management 44.4.1.1 Systemic Pain Control 44.4.1.2 Local Pain Control 44.4.1.3 Technique for the Placement of Subpleural Catheters After Robotic Surgery 44.4.2 Chronic Pain 44.4.3 Multimodality Approach to Pain Management Video Legends References Part III: Esophageal and Foregut Section 45: Robotic Laparoscopic Gastroesophageal Valvuloplasty (Modified Belsey Fundoplication) for Gastroesophageal Reflux Disease 45.1 Introduction 45.2 Historical Background 45.2.1 Concept of Reflux Esophagitis 45.2.2 Mechanism of GERD 45.2.3 Hiatal Hernias 45.2.4 Reflux Disease Due to Impairment of the Barrier Function of the Esophageal Mucosa 45.2.5 Barrett’s Disease 45.2.6 Anatomic Counterpart to the HPZ on Manometry 45.2.7 Treatment of Gastroesophageal Reflux 45.3 Results of Antireflux Procedures 45.3.1 Comparison of Nissen Fundoplication Gastroesophageal Valvuloplasty (Modified Belsey): Laboratory Model of GERD 45.3.2 Gastroesophageal Valvuloplasty 45.4 Laparoscopic Gastroesophageal Valvuloplasty (Modified Belsey) 45.4.1 Posterior Crural Closure 45.4.2 Anterior Crural Closure 45.4.3 Belsey Fundoplasty 45.5 Results 45.5.1 Conventional Laparoscopy Compared to the Robotic Approach 45.6 Robotic Laparoscopic Gastroesophageal Valvuloplasty (Modified Belsey Fundoplasty) 45.6.1 Results 45.6.2 Early (1–12 Weeks) Postoperative Results 45.6.3 Late Follow-Up Video Legends References 46: Robotic Nissen Fundoplication 46.1 Introduction 46.2 Indications for Nissen Fundoplication 46.3 Contraindications to Nissen Fundoplication 46.4 Pre-operative Assessment 46.5 Operative Technique 46.5.1 Patient Preparation and Positioning 46.5.2 Trocar Sites 46.5.3 Obtaining Exposure 46.5.4 Dissection and Mobilization of the Esophagus 46.5.5 Division of Short Gastric Vessels 46.5.6 Correcting the Hiatal Hernia with Crural Closure 46.5.7 Creation and Fixation of the Wrap 46.5.8 Completion of the Operation 46.6 Complications of Nissen Fundoplication 46.7 Advantages and Disadvantages of the Robotic Approach 46.8 Summary References 47: Robotic Gastric Bypass as an Antireflux Procedure 47.1 Introduction 47.2 Diagnosis of Reflux 47.2.1 Anatomic Diagnosis of Reflux 47.2.2 Physiologic Diagnosis of Reflux 47.3 Treatment of Reflux 47.3.1 Medical Treatment of Reflux 47.3.2 Surgical Treatment of Reflux 47.3.3 Reflux and the Patient with Obesity 47.3.4 Persistent Reflux after Antireflux Surgery 47.3.5 Barrett’s Esophagus 47.4 Comparison of Laparoscopic and Robotic Procedures 47.5 Indications for Surgery 47.6 Preoperative Workup 47.7 Operative Steps 47.7.1 Patient Positioning 47.7.2 Port Positioning 47.7.3 Operative Procedure 47.8 Postoperative Care 47.9 RYGB as AntiReflux Operation—Outcomes 47.10 Conclusion References 48: Robotic Surgery for Reflux Disease 48.1 Epidemiology 48.2 Pathophysiology 48.2.1 Motor Anomalies 48.2.2 Anatomical Anomalies 48.2.3 Impaired Mucosal Resistance 48.3 Pathophysiology of GERD in Obese Patients 48.3.1 Defective Gastroesophageal Barrier 48.3.2 Defective Esophageal Clearance 48.3.3 Altered Hormonal Profile 48.3.4 Diet 48.3.5 Visceral Sensitivity 48.4 Natural History of GERD 48.4.1 Obesity 48.4.2 Genetics 48.4.3 Tobacco Smoking 48.4.4 Pregnancy 48.4.5 Hiatal Hernia 48.4.6 Medications 48.4.7 Foods 48.5 Diagnosis of GERD 48.5.1 Presumptive Diagnosis 48.5.2 Diagnostic Evaluation 48.5.3 PPI Trial 48.5.4 Ambulatory Reflux Monitoring 48.5.5 Esophageal Manometry 48.6 GERD and Esophageal Adenocarcinoma 48.6.1 Barrett’s Esophagus (BE) 48.6.2 Temporal Trends of GERD and Barrett’s Esophagus 48.6.3 Obesity 48.6.4 Tobacco Smoking 48.6.5 Alcohol Consumption 48.6.6 Dietary Factors 48.6.7 Antireflux Therapies 48.6.8 Weight Loss 48.6.9 Microbes 48.6.10 Physical Activity and Sedentary Behavior 48.6.11 Hormone and Reproductive Factors 48.6.12 Medications 48.7 Clinical Treatment 48.7.1 Lifestyle 48.7.2 PPIs 48.8 Indications for Antireflux Surgery 48.8.1 Inadequate Symptom Control 48.8.2 Symptoms and Large Hiatal Hernia 48.8.3 Poor Compliance with Medical Treatment 48.8.4 Cost of Medical Therapy 48.8.5 Side Effects of Medical Treatment 48.8.6 Young Patients 48.9 Surgical Treatment 48.9.1 Laparoscopic Fundoplication: Controversial Surgical Aspects 48.9.2 Division of Short Gastric Vessels 48.9.3 Insertion of the Bougie into the Esophagus and Across the Esophageal Junction 48.9.4 Laparoscopic Fundoplication: Total or Partial? 48.9.4.1 Anterior 180° vs. LTF 48.9.4.2 Anterior 90° vs. LTF 48.9.4.3 Posterior vs. LTF 48.9.4.4 Novel Laparoscopic Procedures for Gastroesophageal Reflux Disease 48.10 Side Effects of Antireflux Surgery 48.11 Outcomes of Laparoscopic Antireflux Surgery 48.12 Revision Surgery for GERD 48.13 Robotic Fundoplication for GERD 48.14 Step by Step: How I Make Robotic Fundoplication 48.14.1 Trocar Positioning 48.14.2 Surgical Steps References 49: Robotic-Assisted Paraesophageal Hernia Repair 49.1 Introduction 49.2 Indications 49.3 Patient Preparation 49.4 Operating Room Setup 49.5 Patient Positioning 49.6 Port Placement 49.6.1 Note 49.7 Reduction of the Hernia and Dissection of the Hernia Sac 49.7.1 Note 49.8 Esophageal Mobilization 49.8.1 Note 49.9 Closure of the Crura 49.9.1 Note 49.10 Mesh Reinforcement 49.10.1 Note 49.11 Antireflux Procedure 49.11.1 Note 49.12 Robotic-Assisted Reoperative Foregut Surgery 49.13 Operative Principles for Robotic Revisional Foregut Surgery 49.14 Postoperative Instructions 49.15 Outcomes References 50: Robotic Anatomic and Physiologic Reconstruction of Paraesophageal Hiatal Hernias: Combining Lessons from a Century of Discovery and Controversy 50.1 Introduction 50.2 Historic Perspective 50.2.1 Anatomic Approach to the Repair of Hiatal Hernias: An Erroneous Extrapolation from the Experience with Abdominal Wall Hernias 50.2.2 Functional Repair of Hiatal Defects and the Concept of Gastroesophageal Reflux 50.2.3 The Concept of Short Esophagus 50.3 The Role of the Esophageal Hiatus in the Gastroesophageal Antireflux Mechanism 50.4 Hiatal Hernias 50.4.1 Classification 50.4.1.1 Types I–IV: Akerlund Classification from 1926 50.4.1.2 Classification Based on Clinical Presentation and Intended for Surgical Decision-Making 50.4.2 Pathophysiology and Clinical Presentation 50.4.2.1 Clinical Stage I: Gastroesophageal Reflux Disease GERD 50.4.2.2 Stage II: Gastrointestinal, Aerodigestive, Pulmonary, Cardiovascular, Gastric, and Hematologic Symptoms 50.4.2.3 Esophageal Symptoms 50.4.2.4 Upper Aerodigestive Symptoms 50.4.2.5 Pulmonary Symptoms 50.4.2.6 Cardiovascular Symptoms 50.4.2.7 Gastric Symptoms 50.4.3 Diagnosis 50.4.4 Indications for Surgery 50.5 Technique 50.5.1 Preoperative Evaluation 50.5.2 Anesthesia Management 50.5.3 Port Placement 50.5.4 Positioning and Introduction of the Robot 50.5.5 The Operation Is Divided into Seven Steps 50.5.5.1 Step 1: Dissection of the Right Side of the Hiatal Defect 50.5.5.2 Step 2: Dissection of the Arch of the Esophageal Hiatus 50.5.5.3 Step 3: Dissection of the Left Side of the Hiatal Defect 50.5.5.4 Step 4: Encircling the Esophagus 50.5.5.5 Step 5: Completion of the Mediastinal Dissection 50.5.5.6 Step 6: Anatomic and Physiologic Repair of the Esophageal Hiatus 50.5.5.7 Step 7: Evacuation of CO2 and Port Closure 50.5.6 Postoperative Management 50.5.6.1 Immediate Postoperative Care 50.5.6.2 Long-Term Care 50.6 Results 50.7 Conclusion Appendix References 51: Redo Hiatal Hernia Surgery: Robotic Laparoscopic Approach 51.1 Introduction 51.2 Diagnostic Tools: When to Consider Surgical Repair 51.3 Categorizing Failed Repairs 51.4 Indications for Redo Surgery 51.5 Robotic Approach to Redo Hiatal Hernia Surgery 51.6 Summary/Conclusion References 52: Redo Hiatal Hernia Surgeries: Robotic Thoracoscopic Approach 52.1 Introduction 52.2 Alternative Surgical Approaches in Redo Hiatal Hernia Repair 52.3 Development of the Robotic Thoracoscopic Redo Hiatal Hernia Procedure (RATAS) 52.3.1 Positioning 52.3.2 Trocar Placement 52.3.3 Surgical Procedure References 53: Robotic Esophageal Myotomy for Achalasia 53.1 Introduction 53.2 Diagnosis 53.3 Treatment 53.3.1 Medical Therapy 53.3.2 Botulinum Toxin Injection 53.3.3 Pneumatic Dilation 53.3.4 Surgery 53.3.4.1 Laparoscopic Approach 53.3.4.2 Thoracoscopic Approach 53.3.4.3 Phase I: VATS with Intraoperative Manometry 53.4 Operative Technique 53.4.1 Anesthesia 53.4.2 Patient Positioning 53.4.3 Myotomy 53.4.4 Robotic Laparoscopic Approach 53.4.5 Surgical Technique 53.5 Comparison of Robotic Lateral Heller Myotomy Without Fundoplication (RLHM) to Robotic Anterior Heller Myotomy With Dor Fundoplication (RAHM) 53.5.1 Hypothesis 53.5.2 Study Design 53.5.3 Results 53.6 Comparison of Robotic Laparoscopic Lateral Heller Myotomy Without Fundoplication to Peroral Esophageal Myotomy (POEM) Video Legends References 54: Robotic Ivor-Lewis Esophagectomy 54.1 Historical Background 54.2 Epidemiology 54.3 Therapeutic Strategies 54.3.1 Preoperative Neoadjuvant Chemotherapy Alone 54.3.2 Preoperative Neoadjuvant Radiotherapy Alone 54.3.3 Preoperative Neoadjuvant Combined Chemoradiation Therapy 54.4 Pretreatment Strategy 54.4.1 Computer Axial Tomography (CT) 54.4.2 Esophageal Ultrasound (EUS) 54.4.3 Positron Emission Tomography (PET) 54.5 Extent of Tumor and Nodal Resection 54.6 Surgical Therapy 54.6.1 Transhiatal Esophagectomy (THE) 54.6.2 Ivor Lewis Procedure, Right Thoracic Abdominal Approach (ILE) 54.6.3 The McKeown Variation on the Ivor-Lewis Procedure 54.7 Video-Assisted, Minimally Invasive Techniques for Esophagectomy 54.7.1 Thoracoscopic Esophageal Mobilization Combined with Conventional Transhiatal Esophagectomy 54.7.2 Total Laparoscopic Transhiatal Esophagectomy 54.7.3 Combined Laparoscopic and Thoracoscopic Approach with Cervical Esophagogastrostomy (MIE McKeown) 54.7.4 Minimally Invasive Ivor-Lewis Esophagectomy (MIILE) 54.8 Minimally Invasive Laparoscopic/Thoracoscopic Ivor Lewis Esophagogastrectomy (MIILE) 54.8.1 Laparoscopy 54.8.2 Thoracoscopy 54.8.3 Results 54.9 Robotic Esophagectomy 54.9.1 Abdominal Dissection 54.9.2 Thoracic Dissection and Esophagogastric Anastamosis 54.9.3 Results 54.9.4 Conclusions Video Legends References 55: Totally Robotic Ivor Lewis Esophagectomy 55.1 Introduction and Historical Background 55.2 Indications 55.3 Preoperative Planning 55.4 Surgical Technique 55.5 Anesthetic Considerations 55.6 Endoscopic Evaluation 55.7 Abdominal Phase 55.8 Thoracic Phase 55.9 Postoperative Care 55.10 Prone Position 55.11 Anesthetic Issues 55.12 Cost 55.13 Resident Training 55.14 Outcomes 55.15 Conclusion Video Legend References 56: Robotic Esophagectomy: The European Experience 56.1 Robotic Abdominal Phase: Preparation, Positioning, and Trocar Placement 56.2 Robotic Abdominal Phase: Operative Procedure 56.3 Robotic Thoracic Phase: Preparation, Positioning, and Trocar Placement 56.4 Robotic Thoracic Phase: Operative Procedure 56.5 Conclusion References 57: Robot-Assisted Minimally Invasive Esophagectomy in China 57.1 Introduction 57.2 Consensus on RAMIE in China 57.2.1 Surgical Approach 57.2.2 Anesthesia and Position 57.2.3 Robotic Arm Arrangement 57.2.4 Skeletonization of RLN 57.2.5 Total Meso-esophageal Excision 57.2.6 Learning Curve 57.2.7 Unplanned Events During RAMIE 57.2.8 Complications 57.3 RAMIE in Shanghai Chest Hospital 57.3.1 Patient’s Position 57.3.2 Trocar Arrangement 57.3.3 Thoracic Procedures 57.3.3.1 Mobilization of Right Upper Mediastinum 57.3.3.2 Transection of the Arch of the Azygos Vein 57.3.3.3 Mobilization of the Upper and Middle Thoracic Esophagus 57.3.3.4 Lymph Node Dissection Along the Left RLN (106recL) 57.3.4 Abdominal Procedures 57.3.5 Postoperative Care 57.4 Research Progression of RAMIE in Shanghai Chest Hospital 57.5 Conclusion References Part IV: Bariatric Surgery Section 58: Economics of Robotic Bariatric Surgery in Europe 58.1 Introduction References 59: Robotic Roux-En-Y Gastric Bypass (RA-RYGB) 59.1 Introduction 59.2 Operating Room Setup 59.3 Patient Positioning 59.4 Port Placement 59.5 Operative Technique 59.5.1 Instrumentation 59.5.2 Creation of Gastric Pouch 59.5.3 Creation of the Omega Loop and Blind Loop (Candy Cane) 59.5.4 Creation of the Jejuno-Jejunostomy (JJA) and Closure of the Mesenteric Defects 59.5.5 Creation of Gastrojejunostomy Anastomosis 59.6 Outcomes References 60: The Learning Curve for Robotic Roux-en-Y Gastric Bypass 60.1 Introduction 60.2 Learning Curve: Definition 60.3 Learning Curve for Laparoscopic Roux-En-Y Gastric Bypass 60.4 Introduction of Robotics in Bariatric Surgery 60.5 Technical Advantages of Robotics in Bariatric Surgery 60.6 Learning Curve for Robotic Roux-En-Y Gastric Bypass 60.7 Conclusions References 61: Robot-Assisted Biliopancreatic Diversion with Duodenal Switch 61.1 Introduction 61.2 History and Previous Approaches 61.3 Indications for Surgery 61.4 Clinical Findings 61.4.1 Physiologic Background 61.4.2 Expected Outcomes 61.4.3 Preoperative Considerations 61.4.4 Revision Patients 61.5 Preoperative Testing 61.6 Surgical Technique 61.6.1 Patient Positioning 61.6.2 Abdominal Entry and Port Placement 61.6.3 Appendectomy and Bowel Measurements 61.6.4 Cholecystectomy 61.6.5 Duodenal Dissection and Duodenoileostomy 61.6.6 Sleeve Gastrectomy 61.6.7 Ileo-ileal Anastomosis 61.6.8 Completion of the Procedure 61.7 Comments 61.8 Conclusions References 62: Robotic Sleeve Gastrectomy 62.1 Introduction 62.2 Surgical Technique 62.3 Outcomes 62.4 Conclusion References 63: Robotic Sleeve Gastrectomy 63.1 Background and Epidemiology 63.2 Diagnosis 63.3 Indications 63.4 Surgical Anatomy 63.5 Preoperative Care 63.6 Operative Steps 63.6.1 Pneumoperitoneum, Trocar Placement, and Initial Dissection 63.6.2 Sleeve Calibration, Section, and Extraction 63.7 Postoperative Care 63.8 Complications 63.8.1 Gastric Leak 63.8.2 Gastric Strictures and Gastric Outlet Obstruction 63.8.3 Gastric Dilation 63.8.4 Gastroesophageal Reflux 63.8.5 Dumping Syndrome 63.8.6 Excessive Skin 63.9 Outcomes 63.9.1 Weight Loss 63.9.2 Comorbidities 63.9.3 Quality of Life 63.10 Long-Term Management 63.10.1 Diet 63.10.2 Supplementation 63.10.3 Exercise 63.10.4 Behavioral Health 63.11 Cost 63.12 Education and the Future References 64: Robotic Revisional Bariatric Surgery 64.1 Introduction 64.2 Preoperative Assessment 64.3 Patient Selection for Robotic Revisional Bariatric Surgery 64.4 Technical Aspects of Robotic Revisional Bariatric Surgery 64.5 Operating Room Setup 64.6 Patient Positioning 64.7 Access/Port Placement 64.8 Surgical Technique 64.8.1 Adhesiolysis 64.8.2 Hiatal Hernia Repair 64.8.3 Identification of the Surgical Anatomy (Upper Endoscopy/TilePro) 64.8.4 Anatomy Takedown/Reconstruction 64.8.5 GI Reconstruction 64.9 Outcomes References Part V: General Surgery Section 65: Single Site: Historical Perspectives and Current Application 65.1 Introduction 65.2 Single-Site Robotic Cholecystectomy (SSRC) 65.2.1 SSRC Material 65.2.2 SSRC Technique 65.2.3 Fluorescent Cholangiography in Single-Site Robotic Cholecystectomy 65.3 Single-Site Robotic Colectomies (SSRC) 65.4 Single-Site Robotic Right Colectomy (SSRRC) 65.4.1 Technique of SSRRC 65.4.2 ICG Fluorescence in SSRRC 65.4.2.1 Surgical Stumps and Anastomosis Perfusion Evaluation 65.4.2.2 Sentinel Node, Lymphatic Mapping, and Lymph Flow Evaluation 65.5 Future Perspectives: The da Vinci® SP Platform 65.6 Conclusions References 66: Robotic Single-Site Surgery 66.1 Introduction 66.2 Available Platforms: Access Devices 66.3 Configuration of Robotic Arms and Instrument Articulation 66.3.1 Crossing of the Robotic Arms 66.3.2 Reassigning of the Robotic Arms 66.4 Equipment 66.4.1 Port 66.4.2 Cannulas 66.4.3 Instruments/Accessories 66.4.4 Setup 66.5 Learning Curve 66.6 Evidence 66.7 General Surgery 66.7.1 Colorectal Surgery 66.7.2 Upper Gastrointestinal Surgery 66.7.3 Gallbladder Surgery 66.7.4 Adrenal Surgery 66.7.5 Pancreatic Surgery 66.7.6 Splenectomy 66.8 Urology 66.9 Gynecology 66.10 Future Direction 66.11 Conclusion References 67: Single-Site Systems in General Surgery 67.1 Introduction 67.2 Robotic Laparoendoscopic Single-Site Surgery 67.2.1 Cholecystectomy 67.2.2 Colorectal Surgery 67.2.3 Thyroidectomy 67.2.4 Other General Surgery Procedures 67.3 Future Perspectives of Robotic Single-Site Surgery 67.3.1 The da Vinci SP 67.3.2 Single-Port Orifice Robotic Technology (SPORT) 67.3.3 Flexible Robotic Endoscopic Surgery 67.3.3.1 The Master and Slave TransEndoluminal Robot 67.3.3.2 The Flex Robotic System 67.3.3.3 Ion 67.3.3.4 Monarch 67.4 Conclusion References 68: The Use of the Robot for Abdominal Oncologic Procedures 68.1 Stomach 68.1.1 Introduction 68.1.2 Surgical Techniques 68.1.3 Robot-Assisted Subtotal Gastrectomy (RASG) 68.1.4 Robot-Assisted Total Gastrectomy (RATG) 68.1.5 Robotic D2 Lymphadenectomy 68.1.6 Outcomes 68.2 Liver 68.2.1 Introduction 68.2.2 Robotic Right Hepatectomy 68.2.3 Robotic Left Hepatectomy 68.2.4 Robotic Left Lateral Sectionectomy 68.2.5 Robotic Segmentectomies and Subsegmentectomies 68.2.6 Outcomes 68.3 Pancreas 68.3.1 Introduction 68.3.2 Pancreaticoduodenectomy (PD) 68.3.3 Robotic Distal Splenopancreatectomy (DSP) 68.3.4 Outcomes 68.4 Colon-Rectum 68.4.1 Introduction 68.4.2 Robotic Right Colectomy 68.4.3 Complete Mesocolic Excision 68.4.4 Robotic Left Colectomy 68.4.5 Robotic Rectal Anterior Resection 68.4.6 Outcomes References 69: Robotic Hepatic Lobectomies 69.1 Introduction 69.2 Patient Selection 69.3 Right Hepatectomy 69.3.1 Patient Positioning and Port Placement 69.3.2 Operating Room Setup, Cart Positioning, and Robot Docking 69.3.3 Recommended Instruments 69.3.4 Step-by-Step Right Hepatectomy 69.3.4.1 Preliminary Steps 69.3.4.2 Hilum Dissection 69.3.4.3 Hepatocaval Dissection 69.3.4.4 Parenchymal Transection 69.4 Left Hepatectomy 69.4.1 Patient Positioning and Port Placement 69.4.2 Step-by-Step Left Hepatectomy 69.4.2.1 Hilum Dissection 69.4.2.2 Hepatocaval Dissection 69.4.2.3 Parenchymal Transection 69.5 Personal Experience References 70: Robotic Hepatic Segmentectomies and Wedge Resections 70.1 Introduction 70.2 Patient Selection 70.3 Patient Positioning and Port Placement 70.4 Operating Room Setup, Cart Positioning, and Robot Docking 70.5 Recommended Instruments 70.6 Left Lateral Segments 70.7 Anterior Segments 70.8 Postero-superior Segments 70.9 Wedge Resections 70.10 Personal Experience References 71: Robotic Hepatic Resection 71.1 Introduction 71.2 Indications and Contraindications 71.3 Preoperative Assessment 71.4 Operative Technique 71.5 Room Setup 71.6 Right Hepatectomy 71.7 Left Hepatectomy 71.8 Postoperative Management 71.9 Advantages and Disadvantages of Robotic Approach to Hepatectomies 71.10 Summary 72: Robotic Hepatectomy 72.1 Introduction 72.2 Patient Selection for Robotic-Assisted Liver Surgery 72.3 Technical Approach to Robotic Liver Surgery 72.4 Limitations of Robotic Liver Surgery 72.5 Literature Review 72.6 Summary References 73: Robotic Pancreaticoduodenectomy (Whipple) 73.1 Introduction 73.2 Patient Selection 73.3 Patient Positioning and Port Placement 73.4 Operating Room Setup, Cart Positioning, and Robot Docking 73.5 Recommended Instruments 73.6 Step-by-Step Pancreaticoduodenectomy 73.6.1 Dissection Phase 73.6.2 Reconstruction Phase 73.7 Personal Experience References 74: Robotic Distal Pancreatectomy 74.1 Introduction 74.2 Patient Selection 74.3 Patient Positioning and Port Placement 74.4 Operating Room Setup, Cart Positioning, and Robot Docking 74.5 Recommended Instruments 74.6 Step-by-Step Spleen-Preserving Distal Pancreatectomy 74.7 Step-by-Step En Bloc Distal Splenopancreatectomy 74.8 Personal Experience References 75: Robotic Pancreatectomy 75.1 Introduction 75.2 Robotic Pancreaticoduodenectomy 75.2.1 Positioning 75.2.2 Operative Steps 75.3 Robotic Distal Pancreatectomy 75.3.1 Positioning 75.3.2 Operative Steps References 76: Robotic Cholecystectomy 76.1 Background 76.2 Diagnosis 76.3 Indications 76.3.1 General 76.3.2 Special Patient Populations 76.3.2.1 Anatomic Variations 76.3.2.2 Obese 76.3.2.3 Pediatric 76.3.2.4 Cirrhosis 76.3.2.5 Pregnant 76.4 Surgical Anatomy 76.5 Preoperative Care 76.5.1 Patient Preparation 76.5.2 Equipment Needed 76.5.2.1 Multiport 76.5.2.2 Single Port 76.5.3 Anesthesia 76.5.4 Room Setup and Patient Positioning 76.6 Operative Steps 76.6.1 Multiport 76.6.1.1 Access and Port Placement 76.6.1.2 Dissection 76.6.2 Single Port 76.6.2.1 Access and Port Placement 76.6.2.2 Dissection 76.7 Intraoperative Biliary Imaging 76.7.1 Cholangiography 76.7.2 Fluorescence Cholangiography Utilizing Indocyanine Green 76.8 Postoperative Care 76.9 Outcomes 76.10 Cost 76.11 Education and Future References 77: Gallbladder Cancer 77.1 Introduction 77.2 Special Anatomic Considerations 77.3 Operative Indications Based on the Clinical Stage 77.4 The Development of Minimally Invasive Surgery for Gallbladder Cancer 77.5 Surgical Technique 77.5.1 Setup of the Surgical Robotic System in the Operating Room 77.5.2 Establishment of Carbon Dioxide Pneumoperitoneum and Trocar Position 77.5.3 Operative Details 77.5.4 Conversion to Open Surgery 77.6 Current Status of Robotic Radical Resection for Gallbladder Cancer 77.7 Summary References 78: Robotic HPB Surgery in Children 78.1 Introduction 78.2 Liver Tumours and Cysts 78.2.1 Liver Cysts 78.3 Choledochal Cyst 78.4 Biliary Atresia 78.5 Cholecystectomy 78.6 Splenectomy 78.7 Partial Splenectomy/Splenic Cystectomy 78.8 Single-Port Robotics 78.9 Conclusion References 79: Robotic Adrenalectomy 79.1 Introduction 79.2 Patient Selection 79.3 Surgical Approaches 79.3.1 Robotic Lateral Transabdominal Adrenalectomy 79.3.2 Robotic Posterior Retroperitoneal 79.4 Partial Adrenalectomy 79.5 Perioperative Outcomes 79.6 Learning Curve 79.7 Obese Patients 79.8 Large Tumors 79.9 Malignancy 79.10 Fluorescence Imaging 79.11 Cost 79.12 Conclusion References 80: Laparoscopic/Robotic Treatment of the Small Bowel Lesions 80.1 Introduction 80.2 Patient Selection 80.3 Patient Positioning and Port Placement 80.4 Operating Room Setup, Cart Positioning, and Robot Docking 80.5 Recommended Instruments 80.6 Surgical Technique 80.6.1 Surgical Technique: Neoplastic Disease 80.6.2 Technique: Not-Neoplastic Disease 80.6.3 Institutional Experience References 81: Robotic Small Bowel Resection 81.1 Introduction 81.1.1 Indications 81.2 Technique 81.2.1 Trocar Placement 81.2.2 Docking 81.2.3 Near-Infrared Fluorescence Imaging 81.3 Postoperative Care 81.3.1 Patient Mobilization 81.3.2 Ileus Prevention 81.3.3 Postoperative Fluid Management 81.3.4 Urinary Catheters References 82: Robotic Decompression of Celiac Axis for Median Arcuate Ligament Syndrome 82.1 Introduction 82.2 Techniques of Robotic Incision of Median Arcuate Ligament References 83: Robotic Inguinal Hernia Repair 83.1 Introduction 83.2 Patient Selection 83.3 Patient Positioning and Port Placement 83.4 Operating Room Setup, Cart Positioning, and Robot Docking 83.5 Recommended Instrument 83.6 Step-by-Step Procedure 83.6.1 Flap Dissection 83.6.2 Cooper’s Ligament 83.6.3 Hernia Sac Dissection 83.6.4 Mesh Placement 83.6.5 Flap Closure 83.7 Institutional Experience References 84: Robotic Ventral Hernia Repair 84.1 Introduction 84.2 Patient Selection 84.3 Patient Positioning and Port Placement 84.4 Operating Room Setup, Cart Positioning, and Robot Docking 84.5 Recommended Instruments 84.6 Step-by-Step Procedure 84.6.1 Lysis of Adhesions 84.6.2 Hernia Content Reduction 84.6.3 Hernia Sac Management 84.6.4 Defect Closure 84.6.5 Mesh Placement 84.7 Institutional Experience References 85: Robotic TAPP for Inguinal Hernia Simple to Complex 85.1 Introduction 85.2 Surgical Technique 85.2.1 Patient Selection and Preoperative Preparation 85.2.2 Operative Setup 85.2.3 Technical Highlights and Anatomical Landmarks 85.2.4 Mesh Placement and Closure 85.2.5 Postoperative Care 85.3 Complex Case Considerations 85.3.1 Recurrence 85.3.2 Inguinal Hernia Surgery After Prostatectomy 85.3.3 Large Inguinal-Scrotal Hernias References 86: Robotic Transabdominal Preperitoneal Ventral Hernia Repair (rTAPP VHR) 86.1 Introduction 86.2 Preoperative Considerations and Workup 86.3 Technique, Technical Considerations, and Approach 86.3.1 Port Positioning, Docking, and Instrumentation 86.3.2 Adhesiolysis and Developing a Preperitoneal Plane 86.3.3 Primary Closure of Defect 86.3.4 Mesh Placement, Fixation, and Reperitonealization 86.4 Conclusion References 87: Robotic Abdominal Wall Reconstruction: Approaches for Primary Ventral, Incisional, and Recurrent Hernias 87.1 Introduction 87.2 Preoperative Evaluation and Patient Selection 87.3 Robotic Intraperitoneal Onlay Mesh Repair (rIPOM) 87.3.1 Surgical Technique 87.3.2 Operative Setup 87.3.3 Technical Highlights 87.3.4 Mesh Placement and Closure 87.4 Robotic Transabdominal Preperitoneal Repair (rTAPP) 87.4.1 Surgical Technique 87.4.2 Technical Highlights 87.4.3 Mesh Placement and Closure 87.5 Robotic Retromuscular Mesh Repair 87.5.1 Surgical Technique 87.5.2 Operative Setup 87.5.3 Technical Highlights 87.6 Robotic Transversus Abdominis Release 87.6.1 Surgical Technique 87.6.2 Operative Setup 87.6.3 Technical Highlights 87.6.4 Postoperative Care 87.7 Complex Case Considerations: Recurrent Ventral Hernias References 88: Robotic Transversus Abdominis Release (RoboTAR) 88.1 Introduction 88.2 Overview 88.3 Preoperative Considerations 88.3.1 Advantages 88.3.2 Patient Considerations 88.3.3 Contraindications 88.4 Operative Technique 88.4.1 Patient Positioning, Trocar Placement, and Docking 88.4.2 Posterior Sheath Mobilization 88.4.3 Top-Down Technique 88.4.4 Bottom-Up Technique 88.4.5 Initial Deployment and Fixation of Mesh, Placement of Trocars on the Contralateral Abdomen, and Redocking 88.4.6 Contralateral Dissection 88.4.7 Closure of the Posterior Sheath, Final Deployment of Mesh, and Restoration of the Linea Alba 88.5 Postoperative Considerations 88.6 RoboTAR Outcomes 88.7 Conclusion References 89: Robotic Anterior Component Separation 89.1 Introduction 89.2 Description of Technique 89.3 Conclusion References 90: Starting a Robotic Abdominal Wall Surgery Programme in Europe 90.1 Introduction 90.2 Current State of Robotic Abdominal Wall Surgery 90.3 Robotic Abdominal Wall Surgery in Europe 90.4 Surgical Rationale 90.5 Economical Perspective 90.6 Managing the Learning Curve in a Patient-Centred Approach 90.7 Managing and Training the Staff 90.8 Involving Colleagues and Training Residents 90.9 Data Collection and Clinical Research 90.10 Conclusion References 91: Complications in Robotic Surgery: How to Prevent and Treat? 91.1 Operative Preparation 91.2 Complications of the Biliary Tract 91.3 Complications in Hernia Surgery 91.4 Complications in Colorectal Surgery 91.5 Complications in Foregut Surgery References 92: Robotic Transplant Surgery 92.1 Introduction 92.2 Robot-Assisted Living Donor Nephrectomy 92.2.1 Preoperative Donor Evaluation 92.2.2 Surgical Technique: Left Donor Nephrectomy 92.2.3 Discussion 92.3 Robot-Assisted Kidney Transplantation 92.3.1 Surgical Technique: Right-Sided Robotic Kidney Transplant 92.3.2 Discussion 92.4 Robot-Assisted Pancreas Transplantation 92.4.1 Surgical Technique: Left-Sided Robotic Pancreas Transplant 92.4.2 Discussion 92.5 Robot-Assisted Living Donor Hepatectomy 92.5.1 Surgical Technique: Right Lobe Robotic Hepatectomy 92.5.2 Discussion 92.6 Conclusion References Part VI: Urology Section 93: Robot-Assisted Radical Prostatectomy: Keys to Starting and Succeeding 93.1 Background 93.2 A Clear Noble Purpose 93.2.1 Specific 93.2.2 Measurable 93.2.3 Attainable 93.2.4 Relevant 93.2.5 Time-Bound 93.3 The Right Leadership Structure 93.4 Consistent Communication Pathways 93.5 Standardization 93.5.1 Room Setup 93.5.2 Personnel 93.5.3 Instrumentation 93.6 Parallel Tasks 93.6.1 Operating Room Efficiency: Parallel Task Model 93.7 A Continuous Improvement Cycle 93.7.1 Standardize an Operation and the Activities that Support It 93.7.2 Measure the Standardized Operation 93.7.3 Gauge Measurements Against Requirements 93.7.4 Innovate to Meet Requirements and Increase Productivity 93.7.5 Standardize the New, Improved Operations 93.8 Conclusion 94: Surgical Margin in Robot-Assisted Radical Prostatectomy: Does It Matter? 94.1 Introduction 94.2 Positive Surgical Margins: Definition, Incidence, and Role of the Pathologist 94.3 Predictors of Positive Surgical Margins 94.4 Are Positive Surgical Margins a Negative Predictive Factor for Recurrence and Survival? 94.5 Can We Get Better in Reducing Positive Surgical Margins? References 95: Management of Positive Surgical Margins After Radical Prostatectomy 95.1 Introduction 95.2 Definition of Positive Surgical Margin and Close Surgical Margin 95.3 Location of Positive Surgical Margin 95.4 Characteristics of Positive Surgical Margins 95.5 Intraoperative Frozen Section 95.6 Management of Positive Surgical Margins 95.7 Rationale for Close Monitoring 95.8 Rationale for Adjuvant Radiotherapy 95.9 Rationale for Salvage Radiotherapy 95.10 Adjuvant Versus Salvage Radiotherapy 95.11 Androgen Deprivation Therapy 95.12 Molecular Imaging and Genetic Tests for Prostate Cancer 95.13 Conclusion References 96: Key Elements for Approaching Difficult Cases During Urologic Robotic Surgery 96.1 Introduction 96.2 Anticipating Difficult Cases in Robotic Urologic Surgery 96.3 Large Prostate 96.4 Median Lobe 96.5 Prior Intervention for BPH 96.6 Previous Abdominal Surgery 96.7 Previous Herniorrhaphy with Mesh 96.8 Obesity 96.9 Difficulties Associated with a Narrow Pelvis 96.10 Conclusion References 97: Improving Outcomes for Early Return of Potency 97.1 Introduction 97.2 The Anatomy of the Neurovascular Bundles 97.3 Significance of Fascial Planes During Nerve Preservation 97.4 Significance of Thermal Energy and Mechanical Traction 97.5 The Role of the Prostatic Vasculature 97.6 Techniques of Nerve Sparing 97.6.1 Early Retrograde Release of the Neurovascular Bundles 97.6.2 The “Veil of Aphrodite” Technique 97.6.3 Clipless Antegrade Nerve Sparing 97.6.4 Clipless Cautery-Free Technique 97.7 Potency Outcomes After RARP 97.8 Conclusion References 98: Renal Ischemia and Approach to the Renal Hilum in Robotic Partial Nephrectomy: Tips and Tricks 98.1 Introduction 98.2 History 98.3 Preoperative Considerations 98.3.1 Surgeon Experience 98.3.2 Patient Selection 98.4 Surgical Technique 98.4.1 Patient Positioning 98.4.2 Trocar Placement 98.4.3 Instrumentation 98.4.4 Hilar Dissection 98.4.5 Hilar Clamping 98.5 Tips and Tricks 98.5.1 To Clamp the Renal Vein or Not? 98.5.2 What If There Is Substantial Bleeding Despite Clamping? 98.5.3 Hilar Unclamping 98.5.4 What About Hemostatic Agents and Sealers? 98.5.5 Doppler and Near-Infrared Imaging 98.5.6 Strategies to Minimize Ischemia Time 98.6 Conclusion References 99: Robot-Assisted Partial Nephrectomy 99.1 Introduction 99.2 Preoperative Consideration 99.2.1 Indications 99.2.2 Patient Selection and Preparation 99.2.3 Tools to Make Surgical Decision-Making 99.2.3.1 Preoperative Imaging 99.2.3.2 Perioperative Imaging: Indocyanine Green (ICG) 99.2.4 Intraoperative Ultrasound and TilePro 99.3 Surgical Technique 99.3.1 Room Setup and Robot Installation 99.3.2 Patient Positioning and Port Placement 99.3.3 Robot Docking 99.3.4 Robotic Instruments 99.3.5 Retroperitoneal Versus Transperitoneal RAPN 99.3.6 Ischemia and Hilar Control 99.3.7 Surgical Technique (Step by Step) 99.3.8 Tumor Excision 99.3.9 Resection Technique 99.3.10 Renorrhaphy 99.4 Results and Outcomes 99.5 Limitations and Complications 99.5.1 Lack of Haptic Feedback 99.5.2 System Failure 99.5.3 Postoperative Complications 99.6 The Learning Curve for RAPN 99.7 The Future References 100: Robot-Assisted Pyeloplasty 100.1 Introduction 100.2 Patient Presentation, Etiology, and Radiographic Evaluation 100.2.1 Presentation 100.2.2 Etiology 100.2.3 Radiographic Evaluation 100.3 Pre-operative Evaluation and Management 100.4 Surgical Approach 100.4.1 Operating Suite Set-Up 100.4.2 Surgical Site and Trocar Placement 100.4.3 Exposure of the Ureteropelvic Junction 100.4.4 Pyeloplasty 100.4.5 Closure 100.5 Immediate Post-operative Course 100.6 Outcomes: A Review of Contemporary Literature 100.7 Complications 100.8 Follow-Up 100.9 Special Considerations 100.9.1 Concomitant Nephrolithiasis 100.9.2 Horseshoe Kidney 100.10 Novel Approaches to Robot-Assisted Pyeloplasty 100.11 Conclusions References 101: Robot-Assisted Ureteral Reimplantation 101.1 Background 101.2 Indications 101.3 Preoperative Assessment 101.4 Intraoperative Localization of the Ureteral Stricture 101.5 Surgical Techniques 101.6 Discussion of Outcomes References 102: The Role of Robotics in Adrenal Surgery 102.1 Introduction 102.2 Adrenal Diseases: General Aspects 102.3 History of Adrenal Surgery 102.4 Indications for Adrenalectomy 102.4.1 Malignant Neoplasms 102.4.2 Benign Neoplasms 102.5 Indication for Robotic Adrenalectomy 102.6 Surgical Technique 102.6.1 Positioning 102.6.2 Access to the Abdominal Cavity and Pneumoperitoneum 102.6.3 Retroperitoneum Exposure and Vascular Anatomy 102.6.4 Adrenal Resection 102.7 Robotic Adrenalectomy: Outcomes 102.7.1 Role of Robotic Surgery in the Treatment of Adrenal Diseases 102.7.2 Robotic Adrenalectomy for Malignant Tumors 102.8 Retroperitoneal Robotic Adrenalectomy 102.9 Robotic Laparoendoscopic Single-Site (R-Less) Adrenalectomy 102.10 Robotic Partial Adrenalectomy 102.10.1 Technique 102.11 Conclusion References 103: Step-by-Step Approach to Robotic Cystectomy and Extracorporeal Urinary Diversion 103.1 Introduction 103.2 Clinical and Pathological Outcomes 103.3 Oncological Outcomes of RARC 103.4 Indications 103.5 Patient and Preoperative Preparation 103.5.1 Preoperative Preparation/Checklist 103.5.2 Anesthesia and Patient Positioning 103.5.3 Positioning of Operating Room Equipment and Personnel 103.6 Technique 103.6.1 Port Placement and Instruments 103.6.2 Mobilization of the Sigmoid and Left Colon 103.6.3 Development of the Left Paravesical Space and Division of the Left Ureter 103.6.4 The Left Pelvic Lymphadenectomy 103.6.5 Development of the Right Paravesical Space, Right Ureter, and Right Lymphadenectomy 103.6.6 Identification, Ligation, and Division of the Superior Vesical Arteries 103.6.7 Transferring the Left Ureter Through the Sigmoid Mesentery 103.6.8 Tagging the Distal Ileum and Preparing the Tags 103.6.9 Development of the Prerectal and Posterior Vesical Space 103.6.10 Division of the Remaining Inferior Vesical Vessels 103.6.11 Preservation of the Neurovascular Bundles 103.6.12 Mobilization of the Bladder and Completion of the Apical Dissection 103.6.13 Dissection, Ligation, and Division of the Urethra 103.6.14 Specimen Extraction 103.6.15 Extracorporeal Urinary Diversion 103.7 Tips and Pitfalls for RARC 103.8 Postoperative Care 103.9 Conclusion References 104: Robotic-Assisted Radical Cystectomy Outcomes 104.1 Introduction 104.2 Perioperative Outcomes 104.2.1 Estimated Blood Loss 104.2.2 Length of Stay 104.2.3 Operative Time 104.2.4 Postoperative Pain 104.2.5 Differences in Gender and Age 104.3 Complications 104.4 Quality of Life 104.5 Cost 104.6 Oncologic Outcomes 104.7 Demographic and Pathologic Outcomes 104.8 Cancer-Specific Survival, Recurrence, and Overall Survival 104.9 Surgical Margins 104.10 Comparison of RARC with ORC Regarding Surgical Margins 104.11 Lymph Node Status 104.12 Comparison of ORC, LRC, and RARC 104.13 Conclusion References 105: Robot-Assisted Radical Cystectomy: The MD Anderson Approach 105.1 Introduction 105.2 Patient Selection 105.3 Preoperative Preparation 105.4 Equipment 105.5 Positioning 105.6 Initial Access and Port Placement 105.7 Surgical Steps 105.8 Conclusion References 106: Robotic Surgery of the Kidney and Ureter in the Pediatric Population 106.1 Introduction 106.2 Renal Surgery 106.2.1 Pyeloplasty 106.2.1.1 Patient Positioning 106.2.1.2 Port Placement 106.2.1.3 Approach to Target 106.2.1.4 Procedure 106.2.1.5 Postoperative Care 106.2.1.6 Outcomes 106.2.2 Partial/Heminephrectomy 106.2.2.1 Patient Positioning 106.2.2.2 Port Placement 106.2.2.3 Procedure 106.2.2.4 Postoperative Care 106.2.2.5 Outcomes 106.3 Other Collecting System Procedures 106.3.1 Ureteroureterostomy/Pyelostomy 106.3.2 Pyelolithotomy 106.3.3 Nephrectomy 106.4 Vesicoureteral Reflux Surgery 106.4.1 Extravesical Repair 106.4.1.1 Patient Positioning 106.4.1.2 Port Placement 106.4.1.3 Procedure 106.4.1.4 Postoperative Care 106.4.2 Intravesical Repair 106.4.2.1 Patient Positioning 106.4.2.2 Port Placement 106.4.2.3 Procedure 106.4.2.4 Postoperative Care 106.4.2.5 Outcomes 106.5 Future Directions References 107: Robotic-Assisted Laparoscopic Ileocystoplasty and Mitrofanoff Appendicovesicostomy: Technique and Updated Experience 107.1 Introduction 107.2 History 107.3 Evolution of Surgical Approaches 107.4 Preoperative Testing 107.5 Indication for Surgery 107.6 Surgical Technique 107.6.1 Patient Positioning 107.6.2 Prevention of Deep Venous Thrombosis 107.6.3 Surgical Steps 107.7 Comments 107.8 Conclusion References 108: Preparation of the Operating Room, Back Table, and Surgical Team 108.1 Introduction 108.2 Preparation of the Operating Room 108.3 Preparation of the Back Table 108.4 Troubleshooting 108.4.1 Dark Image or Poor Color 108.4.2 Flickering Image 108.4.3 Blurry Image 108.4.4 EndoWrist Instrument Not Engaging 108.4.5 EndoWrist Cautery Not Responding to Footswitch 108.5 The Surgical Team 108.5.1 Training of the Surgical Team References 109: Enhanced Recovery After Surgery (ERAS) in Urology: Where Do We Go From Here? 109.1 Introduction 109.2 History of ERAS 109.3 What Is ERAS 109.3.1 Preoperative Elements 109.3.2 Intraoperative Elements 109.3.3 Post-Operative Elements 109.4 The State of ERAS in Urology 109.5 Current ERAS Pathway in Urology 109.5.1 Preoperative Domains 109.5.1.1 Preoperative Counseling and Education 109.5.1.2 Preoperative Medical Optimization 109.5.1.3 Oral Mechanical Bowel Preparation 109.5.1.4 Preoperative Carbohydrate Loading 109.5.1.5 Preoperative Fasting 109.5.1.6 Preanesthetic Medications 109.5.1.7 Alvimopan Administration 109.5.1.8 Thromboembolic Prophylaxis 109.5.2 Intraoperative Domains 109.5.2.1 Epidural Analgesia 109.5.2.2 Minimally Invasive Approach 109.5.2.3 Antimicrobial Prophylaxis and Skin Preparation 109.5.2.4 Standard Anesthetic Protocol 109.5.2.5 Perioperative Fluid Management 109.5.3 Post-Operative Domains 109.5.3.1 Nasogastric Intubation 109.5.3.2 Thrombosis Prophylaxis 109.5.3.3 Resection Site Drainage 109.5.3.4 Urinary Drainage 109.5.3.5 Prevention of Post-Operative Ileus 109.5.3.6 Prevention of Post-Operative Nausea and Vomiting (PONV) 109.5.3.7 Post-Operative Analgesia 109.5.3.8 Early Mobilization 109.5.3.9 Early Oral Diet 109.5.3.10 ERAS Auditing System 109.6 The Cost of ERAS 109.7 The Future of ERAS in Urology 109.8 Summary References 110: ERAS Protocol in RARP 110.1 Introduction 110.2 Pre-operatively 110.2.1 Pre-operative Steps in RARP ERAS 110.2.2 Primary Care 110.2.3 Outpatient Clinic 110.2.4 Pre-operative Assessment Clinic (POAC) 110.2.5 Cardiopulmonary Exercise Testing (CPET) 110.2.6 Pre-habilitation 110.2.7 Nutrition 110.2.8 Catheter Care 110.2.9 Pelvic Floor Exercises 110.2.10 Psychological Well-Being 110.3 The Day of Surgery 110.4 Intraoperatively 110.4.1 Anaesthetic 110.4.2 Post-Operative Nausea and Vomiting (PONV) 110.4.3 Positioning 110.4.4 Ventilation 110.4.5 Venous Thromboembolism (VTE) Prophylaxis 110.4.6 Patient Warming 110.4.7 Operative Technique 110.4.8 Individual Goal-Directed Intraoperative Fluid Therapy (IGDFT) 110.4.9 Drains and Catheters 110.5 Post-Operatively 110.5.1 Nutrition and Fluids 110.5.2 Analgesia 110.5.3 Mobilisation 110.5.4 Drains 110.6 Discharge From Hospital 110.7 Successful ERAS: Implementation and Quality Assurance 110.7.1 Culture Change 110.7.2 Teamwork and the Patient Journey 110.7.3 “Traditional” Practices 110.8 Conclusion References 111: CUSUM Analysis and the Learning Curve 111.1 Introduction 111.2 CUSUM Analysis 111.3 Procedure-Independent Variables 111.4 Summary References Part VII: Gynecology Section 112: The US Perspective of Benefit of Minimally Invasive Surgery: Why Is This Important Now? 112.1 Introduction 112.2 Hysterectomy 112.3 Myomectomy 112.4 Endometriosis 112.5 Analgesia Requirements 112.6 Costs 112.7 Conclusions References 113: Port Placement and Patient Cart Docking for Robot-Assisted Gynecologic Surgery 113.1 Introduction 113.2 Port Placement for Multi-Port Procedures 113.3 Port Placement for Single-Site Procedures 113.4 Docking of the Patient Cart 113.4.1 Docking for the da Vinci® Si and X Systems 113.4.2 Docking for the da Vinci® Xi System 113.5 Conclusion References 114: Robot-Assisted Laparoscopic Myomectomy 114.1 Introduction 114.2 The Development of Robotic Gynecologic Surgery 114.2.1 Patient Benefits 114.2.2 Surgeon BenefitsK 114.2.3 Disadvantages 114.3 Patient Selection 114.4 Preoperative Imaging 114.5 The Operating Room Setup 114.6 Operative Details 114.7 Results 114.8 Summary References 115: Genital and Extragenital Endometriosis: Video-Laparoscopic with Robotic Assistance 115.1 Introduction 115.2 Application to Endometriosis 115.3 Surgical Approach 115.4 Lysis of Adhesions 115.5 Peritoneal and Tubo-ovarian Endometriosis 115.6 Intestinal Endometriosis 115.7 Genitourinary Endometriosis 115.8 Diaphragmatic and Thoracic Endometriosis 115.9 Conclusion References 116: Robot-Assisted Laparoscopic Hysterectomy 116.1 Introduction 116.2 History of Robotic Surgery in the Field of Gynecology 116.3 Advantages 116.4 Disadvantages 116.5 Preoperative Preparation, Patient Selection, and Anesthesia Considerations 116.6 Basic Setup for the da Vinci® Robotic System 116.7 The Robot-Assisted Laparoscopic Hysterectomy (RALH) 116.8 Patient Positioning 116.9 Uterine Manipulation 116.10 Laparoscopic Entry and Port Placement 116.11 Docking the Bedside Robot 116.12 Switching the Laparoscopic Camera to the Robotic Scope 116.13 EndoWrist Instruments 116.14 Robot-Assisted Laparoscopic Hysterectomy Technique 116.15 Postoperative Care 116.16 Complications of Robotic Surgery 116.17 Conclusion References 117: Video Laparoscopic Management of Adnexal Masses With or Without Robotic Assistance 117.1 Introduction 117.2 Diagnosis 117.2.1 History 117.2.2 Physical Exam 117.2.3 Imaging 117.2.4 Laboratory Studies 117.3 Treatment 117.3.1 Medical Therapy 117.3.2 Surgical Therapy 117.3.3 Surgical Therapy for Benign-Appearing Lesions 117.3.3.1 Ovarian Cysts 117.3.3.2 Endometriomas 117.3.3.3 Ovarian Remnant 117.3.3.4 Surgical Therapy for Probable Malignancy 117.3.3.5 Robotically Assisted Laparoscopic Management of Adnexal Masses 117.4 Conclusion References 118: Robot-Assisted Laparoscopic Microscopic Tubal Anastomosis 118.1 Introduction 118.2 Factors Influencing Successful Tubal Reversal 118.3 Evolution of Tubal Anastomosis 118.4 Robot-Assisted Laparoscopic Tubal Anastomosis 118.4.1 Case Reports and Series 118.4.2 Comparative Studies 118.4.3 Procedure 118.5 Conclusion References 119: Robotic-Assisted Laparoscopic Surgery and Pelvic Floor 119.1 Introduction 119.2 Vaginal Vault Prolapse 119.3 Technique 119.4 Paravaginal/Posterior Defect Repair 119.5 Technique 119.6 Conclusions References 120: Complications in Robotic-Assisted Video Laparoscopic Surgery 120.1 Introduction 120.2 Comparing Different Routes of Hysterectomy 120.3 Operative Time 120.4 Herniation 120.5 Complications Specific to Oncology 120.6 Vaginal Cuff Dehiscence 120.7 Injury Due to Electrocautery 120.8 Gastrointestinal Complications 120.9 Urologic Complications 120.10 Major Vessel Complications 120.11 Conclusion References 121: Robotic Single-Site Gyn Surgery 121.1 Introduction 121.2 Technology 121.3 Technique 121.4 Discussion 121.5 Conclusion References Part VIII: Gynecology Oncology Section 122: Robotic Surgery and Physician Wellness in Gynecologic Oncology 122.1 The Introduction of Robotics into the Field of Gynecology 122.2 An Update on Endometrial Cancer 122.3 Cervical Cancer 122.4 Fertility-Sparing Surgery 122.5 Ovarian Cancer 122.6 Conclusion References 123: Single-Site Robotic Surgery in Gynecology 123.1 History 123.2 Technology of Single-Site and Single-Port Surgery 123.3 Surgical Procedures for Single-Site or Single-Port Robotics 123.3.1 Entry Considerations 123.3.2 Obesity 123.3.3 Insufflation 123.3.4 Anatomic Considerations for Single-Site or Single-Port Surgery 123.3.5 Instrument Availability 123.3.6 Cosmesis 123.3.7 Pain 123.3.8 Procedures 123.4 Current and Future of Single-Site and Single-Port Surgery 123.5 Conclusion References 124: Robotic-Assisted Radical Hysterectomy and Trachelectomy 124.1 Introduction 124.2 History 124.3 Clinical Findings 124.3.1 Oncological Outcomes 124.3.2 Fertility-Sparing Procedures 124.3.3 Advanced or Recurrent Cervical Cancer 124.3.4 Nerve-Sparing Technique 124.3.4.1 Pelvic Innervation 124.3.4.2 Functional Outcomes of a Nerve-Sparing Technique 124.3.4.3 Oncological Outcomes of a Nerve-Sparing Technique 124.4 Surgical Technique 124.4.1 Exploratory Laparoscopy 124.4.2 Sentinel Lymph Node Dissection 124.4.3 Rectovaginal Space 124.4.4 Vesicovaginal Space 124.4.5 Addressing the Adnexa 124.4.6 Paravesical/Paravaginal Space 124.4.7 Pararectal Space 124.4.8 Pelvic Lymphadenectomy 124.4.9 Addressing Uterine Artery 124.4.10 Dissection of the Ureter from the Ureteral Tunnel 124.4.11 Parametrium 124.4.12 Colpotomy and Removal of the Specimen 124.4.13 Closure of Vaginal Cuff 124.5 Trachelectomy Surgical Technique 124.6 Tips and Pitfalls 124.7 Conclusion References Part IX: Cardiovascular Section 125: Robotic CABG via Minithoracotomy: Advantages, Challenges, and Pitfalls 125.1 Introduction 125.2 Benefits of Minimally Invasive Robotic-Assisted CABG 125.3 Safety Challenges in Minimally Invasive Robotic-Assisted CABG 125.4 Training Challenges in Minimally Invasive Robotic-Assisted CABG 125.4.1 Embracing the Early Learning Curve 125.4.1.1 Anesthesia 125.4.1.2 Surgery 125.4.1.3 Perfusion 125.4.2 Managing the Unique Challenges of Robotic CABG 125.4.3 Sustaining the Robotic Program 125.5 Conclusion References 126: Robotically Assisted Hybrid Coronary Intervention 126.1 Introduction 126.2 History and Previous Approaches 126.3 Clinical Findings and Preoperative Testing 126.3.1 Preoperative Testing for Catheter-Based Intervention 126.3.2 Preoperative Testing for Surgery 126.4 Indications for Hybrid Coronary Revascularization 126.4.1 General Thoughts 126.4.2 Indications from the Coronary Anatomy and Pathology View 126.5 Contraindications for Hybrid Coronary Interventions 126.6 Surgical Technique 126.6.1 Surgical Component of Hybrid Interventions 126.6.2 Catheter-Based Component of Hybrid Interventions 126.6.3 Sequence of Robotic Surgery and PCI 126.6.3.1 “PCI First” 126.6.3.2 “Surgery First” 126.6.3.3 “Simultaneous Hybrid Intervention” 126.7 Tips and Pitfalls 126.7.1 Challenges with “Robotic Surgery First” 126.7.2 Challenges with “PCI First” 126.7.3 Challenges with “Simultaneous Hybrid Coronary Intervention” 126.8 Comments and Future Aspects 126.9 Conclusion Video Legend References 127: Robotic Mitral Valve Repair 127.1 Introduction 127.2 History 127.3 Clinical Findings 127.4 Preoperative Testing 127.5 Indications for Surgery 127.6 Surgical Technique 127.6.1 Anesthesia and Patient Preparation 127.6.2 Cannulation 127.6.3 Port Placement 127.6.4 Cardiopulmonary Bypass and Myocardial Protection 127.6.5 Mitral Valve Repair 127.6.6 Posterior Leaflet Repair 127.6.7 Anterior Leaflet Repair 127.6.8 Bileaflet Repair 127.6.9 Annuloplasty 127.6.10 Atriotomy Closure 127.7 Tips and Pitfalls 127.7.1 Conversions 127.7.2 CO2 Insufflation 127.7.3 Transthoracic Cross Clamp 127.7.4 Bleeding 127.7.5 SAM 127.7.6 Artificial Chordae Length 127.7.7 Annuloplasty Band Size 127.8 Advantages and Disadvantages of Robotic Mitral Valve Repair 127.9 Developing a Robotic Surgical Program 127.10 Summary and Future Aspects References 128: Robot-Assisted Vascular Surgery 128.1 Introduction 128.2 History of Laparoscopic and Robotic Surgery 128.2.1 Laparoscopy 128.2.2 Robotics 128.3 Laparoscopic Vascular Surgery 128.4 Surgical Approaches 128.4.1 Transperitoneal Approach (TA) 128.4.2 Retroperitoneal Approach (RA) 128.4.3 Transperitoneal-Retroperitoneal Approach (TRA) 128.4.4 Modified Transperitoneal Approach (mTA) 128.5 Robotic Vascular Surgery 128.5.1 Thromboendarterectomy of the Aorta and Pelvic Artery 128.5.2 Iliofemoral and Aortofemoral Bypass 128.5.3 Aortofemoral Bypass with Central Anastomosis on the Descending Thoracic Aorta 128.5.4 Abdominal Aortic Aneurysm 128.5.5 Iliac Artery Aneurysm 128.5.6 Splenic Artery Aneurysm 128.5.7 Renal Artery Reconstruction 128.5.8 Robotic Treatment of Type II Endoleak after Endovascular Aneurysm Repair 128.5.9 Robotic Surgery for Coeliac Artery Compression Syndrome (Median Arcuate Ligament Syndrome) 128.5.10 Hybrid Robotic Procedures 128.6 Advantages and Disadvantages of Robot-Assisted Vascular Surgery 128.7 Conclusion References Part X: Colorectal Section 129: Robotic Colorectal Surgery: General Considerations 129.1 History 129.2 From Laparoscopic to Robotic Surgery 129.3 Obesity and Robotic Surgery 129.4 Intracorporeal Versus Extracorporeal Anastomosis for Minimally Invasive Right Colectomy 129.5 Left Colectomy and Low Anterior Resection 129.6 Near Future 129.7 Conclusions References 130: Institutional Economics in Robotic Colorectal Surgery 130.1 Introduction 130.2 Market Analysis 130.3 Potential Benefits of Robotic Surgery 130.4 Development of an Institutional Business Plan 130.4.1 Evaluation of Feasibility 130.4.1.1 Internal Resources 130.4.1.2 External Resources 130.4.1.3 Development and Maintenance of Institutional Database for Clinical Outcome Evaluation and Monitoring 130.4.2 Evaluation of Sustainability 130.4.3 Business Plan 130.4.3.1 Evaluation of Fixed Costs 130.4.3.2 Evaluation of Variable Costs 130.4.3.3 Evaluation of Potential Overall Institutional Costs Reduction 130.5 Robotic Colorectal Surgery: Reduction in Complications, Length of Stay and Conversion to Open Surgery 130.6 Breakeven Point 130.7 Structured Training Program in Robotic Colorectal Surgery 130.8 Conclusions References 131: Robotic Colectomy with CME 131.1 Introduction 131.2 Robotic CME with Medial-to-Lateral Approach 131.3 Robotic CME with Bottom-to-Up Approach 131.4 D3 Lymphadenectomy References 132: Robotic Left Colectomy with CME 132.1 Introduction 132.2 Patient Position, Operation Room Setup, and Trocars Layout 132.3 Splenic Flexure Resection with CME 132.3.1 Surgical Technique 132.3.1.1 Vascular Control 132.3.1.2 Coloparietal Detachment 132.3.1.3 Bowel Transection and Intracorporeal Anastomosis 132.4 Left Colectomy with CME 132.4.1 Splenic Flexure Takedown 132.4.2 Vascular Control 132.4.3 Bowel Transection and Anastomosis 132.5 Discussion References 133: Robotic Right Colectomy: The Italian Experience 133.1 Introduction 133.2 Surgical Technique 133.2.1 Patient Positioning, Operating Room Setup, and Trocar Layout 133.2.2 Mesenteric Root Detachment 133.2.3 Vascular Control 133.2.4 Bowel Transection and Intracorporeal Anastomosis 133.2.5 Specimen Extraction 133.3 Results 133.4 Discussion References 134: Minimally Invasive Right Colectomy: Extracorporeal Versus Intracorporeal Anastomosis 134.1 Right Colectomy as a Standard Surgical Technique for Processes Affecting the Right Colon 134.2 Right Colectomy with Minimally Invasive Surgery 134.2.1 Technical Variants of the Anastomosis in Laparoscopic Surgery 134.2.2 Robotic Surgery as an Evolution of Minimally Invasive Surgery 134.2.3 Creation of Anastomosis as a Factor that Influences the Prolonged Operating Time for Right Robotic Colectomy 134.3 Conclusions References 135: Single-Site Minimally Invasive Colectomy 135.1 Introduction 135.2 Minimally Invasive Surgery 135.3 Minimally Invasive Colectomy 135.4 Single-Incision Surgery 135.5 Single-Incision Laparoscopic Colectomy 135.6 Single-Incision Robotic-Assisted Colectomy 135.7 Future Directions References 136: The Technique of a Robotic Low Anterior Resection 136.1 Introduction 136.2 Set-up 136.2.1 Patient Position 136.2.2 Port Positioning 136.2.3 Docking 136.2.4 Instruments 136.3 Ergonomics 136.4 Technical Steps 136.4.1 Patient Set-up 136.4.2 Inferior Mesenteric Artery (IMA) Exposure and Ligation, Development of Medial to Lateral Plane and IMV Division after Exposure 136.4.3 Left Colonic and Splenic Flexure Mobilization 136.4.4 Rectal Dissection 136.4.5 Rectal Stapling, Specimen Extraction, Anastomosis and Closure 136.5 Complications 136.5.1 Position-Related 136.5.2 Inflammatory Response 136.5.3 Low Anterior Resection Syndrome 136.5.4 Off-Camera Injury 136.5.5 Device Failures 136.6 Tips and Tricks 136.6.1 Patient Selection 136.6.2 Simulator 136.6.3 Team Training 136.6.4 Video Recording 136.6.5 Nerve Preservation References 137: Robotic Total Mesorectal Excision for Rectal Cancer 137.1 Introduction 137.2 Clinical Findings 137.3 Preoperative Planning, Patient Workup, and Optimization 137.4 Indications and Contraindications of Approach 137.5 Surgical Technique 137.5.1 General Concepts 137.5.2 Patient Positioning 137.5.3 Robotic Cart Positioning 137.5.4 Port Placement 137.5.5 Robotic Instrument and Function 137.5.6 Specimen Extraction 137.5.7 Robotic Rectal Dissection 137.5.8 Distal Rectal Transection 137.5.9 Reconstruction 137.5.10 Tips and Pitfalls 137.6 Comments 137.6.1 Conclusion References 138: Robotic Transanal Surgery and Navigation for Rectal Neoplasia 138.1 Introduction 138.2 The Evolution of Robotic Transanal Surgery 138.3 Experience and Outcomes: Robotic TAMIS 138.4 Experience and Outcomes: Robotic taTME 138.5 Navigation, Robotics, and taTME 138.6 The Coming Age of Computer-Centric Robots References 139: Pelvic Nerve Function and Robotic Pelvic Surgery: Is There Any Evidence? 139.1 Introduction 139.2 Sympathetic Fibres 139.3 Parasympathetic Fibres 139.4 Challenges in the Pelvis 139.5 Assessment of Urinary and Sexual Function 139.6 Is There Evidence for Improved Nerve Function Following Robotic Surgery? 139.7 Conclusions References 140: Optimizing Sexual and Urinary Outcomes in Robotic TME 140.1 Introduction 140.2 Symptoms of Genitourinary Dysfunction 140.3 Anatomy of the Hypogastric Plexus 140.4 Autonomic Regulation of Sexual and Urinary Functions 140.5 Surgical Phases of Nerve-Sparing TME 140.5.1 Ligation of the Inferior Mesenteric Artery 140.5.2 Posterior Isolation of the Mesorectum 140.5.3 Lateral Dissection 140.5.4 Anterior Dissection 140.6 Technical Aspects Related to the Current Robotic Platforms 140.7 Magnetic Resonance in Nerve-Sparing Rectal Surgery 140.8 Discussion References 141: Robotic Rectal Cancer Surgery: Is There Life After ROLARR? 141.1 Introduction 141.2 Randomised Controlled Trials and Propensity Score Matched Observational Studies Reporting on Robotic Rectal Cancer Surgery 141.3 American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) Reporting on Robotic Rectal Surgery 141.4 Significance of Conversion to Open 141.5 Learning Curve of Robotic Surgery 141.6 Patient Selection: Which Patients with Rectal Cancer Benefit from Robotic Surgery 141.7 The Future of Robotic Surgery 141.8 Conclusion References 142: Robotic Rectal Prolapse Repair 142.1 Introduction 142.2 History 142.3 Previous Approaches 142.3.1 Perineal Approaches 142.3.2 Abdominal Procedures 142.3.2.1 Anterior Resection 142.3.2.2 Ripstein and Wells Rectopexy 142.3.2.3 Suture Rectopexy 142.3.2.4 Resection Rectopexy 142.3.2.5 Laparoscopic Ventral Rectovaginopexy (D’Hoore Procedure) 142.4 Clinical Findings and Preoperative Testing 142.4.1 General 142.4.2 Medical History and Physical Examination 142.4.3 Proctoscopy 142.4.4 Anorectal Endosonography 142.4.5 Anal Manometry 142.4.6 Radiological Evaluation 142.5 Indications for Surgery 142.6 Surgical Technique 142.6.1 Robot-Assisted Ventral Rectopexy 142.6.2 Robotic-Assisted Resection Rectopexy 142.7 Tips and Pitfalls 142.7.1 General 142.7.2 Robot-Assisted Ventral Rectopexy 142.7.3 Robot-Assisted Resection Rectopexy 142.8 Surgical Outcome 142.8.1 Outcome After Minimally Invasive Ventral Rectopexy 142.8.2 Outcome after Minimally Invasive Resection Rectopexy 142.9 Comments 142.10 Conclusion References 143: Benign Diseases: Does the Robot Make Sense? 143.1 Introduction 143.2 Robotic Gastroesophageal Surgery 143.2.1 Technical Details 143.2.1.1 Patient Positioning 143.2.1.2 Robot Positioning and Docking 143.2.1.3 Trocar Placement for da Vinci® Si 143.2.1.4 Trocar Placement for da Vinci® Xi 143.2.2 Robotic Fundoplication for GERD 143.2.3 Robotic Repair of Giant Hiatal Hernia 143.2.4 Robotic Heller Myotomy for Achalasia 143.2.5 Robotic Excision of Epiphrenic Diverticula 143.2.6 Robotic Redo Surgery 143.3 Robotic Splenectomy or Hemisplenectomy 143.3.1 Technical Details 143.3.1.1 Patient Positioning 143.3.1.2 Robot Positioning and Docking 143.3.1.3 Trocar Placement for da Vinci® Si 143.3.1.4 Trocar Placement for da Vinci® Xi 143.3.2 Full Robotic Total Splenectomy: Step-by-Step Technique 143.3.3 Full Robotic Hemisplenectomy: Step-by-Step Technique 143.3.4 Discussion 143.4 Robotic Colorectal Surgery for Complicated Diverticulitis 143.4.1 Technical Details 143.4.1.1 Patient Positioning 143.4.1.2 Robot Positioning and Docking 143.4.1.3 Trocar Placement for da Vinci® Si 143.4.1.4 Trocar Placement for da Vinci® Xi 143.4.2 Single-Docking Full Robotic Sigmoidectomy: Step-by-Step Technique 143.4.3 Discussion References 144: Future and Other Robotic Platforms 144.1 Introduction 144.2 Senhance™ Surgical System (TransEnterix® Surgical, Inc., Morrisville, NC, USA) 144.3 da Vinci SP® Surgical System (Intuitive Surgical, Inc., Sunnyvale, CA, USA) 144.4 FreeHand v1.2® (FreeHand 2010 Ltd., Cardiff, UK) 144.5 Flex® Robotics System (Medrobotics, Corp. Raynham, MA, USA) 144.6 SPORT™ Surgical System (Titan Medical, Toronto, Canada) 144.7 MiroSurg® (Robotics and Mechatronics Center, Oberpfaffenhofen-Weßling, Germany) 144.8 Versius (CMR Surgical, Cambridge, UK) 144.9 Conclusion References Part XI: Otolaryngology Section 145: Bilateral Axillo-Breast Approach (BABA) Robotic Thyroidectomy 145.1 Introduction 145.2 Indications and Contraindications 145.3 Basic Equipment and Instruments 145.4 Patient Position and OR Setup 145.4.1 Patient Position 145.4.2 OR Set-up 145.5 Surgical Procedures of BABA Robotic Thyroidectomy 145.5.1 Preparation 145.5.1.1 Drawing Guidelines 145.5.1.2 Epinephrine-Mixed Saline Injection 145.5.2 Flap Formation with a Rendez-Vous Technique 145.5.2.1 Skin Incision and Blunt Dissection 145.5.2.2 Port Insertion and Sharp Dissection Using an Energy Device 145.5.2.3 Robot Docking 145.5.3 Ipsilateral Thyroid Lobectomy 145.5.3.1 Midline Division and Isthmectomy 145.5.3.2 Lateral Dissection from the Strap Muscles 145.5.3.3 Dissection of the Lower Pole and Central Neck Dissection 145.5.3.4 Preservation of the Recurrent Laryngeal Nerve and Inferior Parathyroid Gland 145.5.3.5 Dissection of the Ligament of Berry 145.5.3.6 Dissection of the Upper Pole and Preservation of the Superior Parathyroid Gland 145.5.4 Specimen Removal and Closure 145.5.4.1 Specimen Removal 145.5.4.2 Closure of the Strap Muscles 145.5.4.3 Skin Closure 145.6 Evidence Updates of BABA Robotic Thyroidectomy 145.6.1 Perioperative Outcomes 145.6.1.1 Cosmetic Satisfaction 145.6.1.2 Operation Time 145.6.1.3 Postoperative Pain and Sensory Change 145.6.1.4 Drain Amount and Hospital Stay 145.6.2 Postoperative Complications 145.6.2.1 RLN Injury and Voice Change 145.6.2.2 Hypoparathyroidism and Hypocalcemia 145.6.2.3 Bleeding and Hematoma 145.6.3 Oncological Outcomes 145.6.3.1 Retrieval of Lymph Nodes 145.6.3.2 Surgical Completeness 145.6.3.3 Recurrence of Disease and Survival 145.6.4 Cost 145.7 Conclusion References 146: Endoscopic and Robotic Thyroidectomy 146.1 Endoscopic and Robotic Thyroidectomy 146.2 Small Incision Video-Assisted Thyroidectomy (MIVAT) 146.2.1 Selection Criteria for MIVAT 146.2.2 Contraindications for MIVAT 146.2.3 Expanded Indications for MIVAT 146.3 Remote Access Endoscopic Thyroidectomy 146.3.1 Axillary Approach to ET 146.3.2 Anterior Chest Approach ET 146.3.3 Axillary Bilateral Breast Approach (ABBA) 146.3.4 Bilateral Axillo-Breast Approach (BABA) 146.3.5 Gasless Approaches to Endoscopic Thyroidectomy 146.3.6 The Technique of Gasless TAA for Thyroidectomy 146.4 Robotic Thyroidectomy 146.4.1 Indications and Contraindications 146.4.2 Transaxillary Access (TAA) Robotic Thyroidectomy Technique 146.4.3 How to Prevent Complications in Robotic TAA Thyroidectomy 146.4.4 Recurrent Laryngeal Nerve 146.4.5 Parathyroid Preservation 146.4.6 Bleeding 146.4.7 Tracheal Injury 146.4.8 Brachial Plexus Injury 146.4.9 Impact of Body Habitus 146.4.10 Outcomes of Robotic Thyroidectomy 146.5 Meta-Analysis of RT Versus Traditional Open Thyroidectomy References 147: Management of Sleep Apnea 147.1 Introduction 147.2 History 147.3 Previous Approaches 147.4 Clinical Findings 147.5 Contraindications 147.6 Preoperative Testing 147.7 Indications and Contraindications for Surgery 147.8 Surgical Technique 147.8.1 TBR 147.8.1.1 Step 1: Right-Side Lingual Tonsillectomy 147.8.1.2 Step 2: Left-Sided Lingual Tonsillectomy 147.8.1.3 Step 3: Residual Obstruction Evaluation 147.8.1.4 Step 4: Additional Resections 147.8.2 SGP 147.9 Additional Surgical Procedures 147.10 Tips, Tricks, and Pitfalls 147.11 Conclusion References 148: Transoral Robotic Surgery for Tonsillar Neoplasms 148.1 Introduction 148.2 Patient Selection and Evaluation 148.3 Relevant Transoral Anatomy 148.3.1 Lateral Oropharynx and Palatine Tonsils 148.3.2 Vessels and Nerves of the Tonsillar Fossae 148.3.3 Lymphatics of Tonsillar Fossa 148.4 Transoral Robotic Oropharyngectomy with Tonsil Excision 148.4.1 Lateral Oropharyngectomy 148.4.2 Neck Dissection 148.4.3 Postoperative Care 148.5 Complications 148.5.1 Bleeding 148.5.2 Neck Abscess 148.5.3 Tongue/Dental Paresthesia 148.5.4 Velopharyngeal Insufficiency (VPI) and Rhinolalia 148.5.5 Delayed Pharyngeal Healing 148.6 Summary References 149: Transoral Robotic Surgery for Supraglottic Neoplasms 149.1 Introduction 149.2 History 149.3 Previous Approaches 149.4 Clinical Findings 149.5 Preoperative Testing 149.6 Indications for Surgery 149.7 Surgical Technique 149.8 Comments 149.9 Conclusion References 150: Future of Robotics in Otolaryngology–Head and Neck Surgery 150.1 Introduction 150.2 History 150.3 Growth Areas 150.3.1 Oropharyngeal Cancer 150.3.2 Skull Base 150.3.3 Larynx 150.3.4 Neck Surgery 150.3.5 Sleep Surgery 150.4 Emerging Technologies 150.5 Conclusion References Index

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