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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_5193_Библиотеки_им_академика_М_И_Перельмана.pdf
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- •Disclaimer for Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) Manual
- •Contents
- •Contributors
- •Commercialization
- •References
- •References
- •3: Asensus Surgical: Senhance Surgical System
- •Asensus Surgical: Senhance Surgical System
- •Senhance System Console
- •Straight Stick Instruments
- •Articulating Instruments
- •Energy
- •Intelligent Surgical Unit
- •Advanced Intelligent Surgical Unit Features
- •Senhance Connect
- •Surgeons Console Design
- •Arm Cart Design
- •The Hugo RAS™ System
- •Robotic Arms
- •The Surgeon’s Console
- •System Tower
- •Arm Cart
- •Hugo Instruments
- •Future Developments
- •References
- •5: Versius Surgical Robot
- •Introduction
- •System Design
- •Surgeon Console
- •Disclaimers
- •The Head-Up Display (HUD)
- •Some Important Icons
- •Alarm Icons
- •Arm Modes
- •Arm Clash
- •System Connections
- •Approved Procedures
- •Some Important Safety Features
- •Conclusion
- •6: Virtual Incision: MIRA Surgical System
- •Introduction
- •The MIRA Surgical System
- •Indication
- •Additional Technical Information
- •Clinical Data
- •Telesurgery
- •Purpose
- •Adopting
- •Operationalizing
- •Standardizing
- •Lessons
- •Conclusion
- •Bibliography
- •Introduction
- •Curricula Components
- •Web-Based Training
- •Virtual Simulation
- •Bedside Skills
- •Console Training
- •Training Programs
- •Intuitive Surgical Da Vinci Curriculum
- •Robotic Training Network (RTN)
- •Conclusion
- •References
- •9: Digital Surgery
- •Introduction
- •Advanced Visualization
- •3D Visualization
- •Fluorescence-Guided Surgery
- •Augmented Reality
- •Current Implementation
- •Enhanced Instrumentation
- •Data Capture
- •Video Data
- •Data Analytics
- •Artificial Intelligence
- •Surgical Decision-Making
- •Skills Assessment
- •Patient Care
- •Automated Surgery
- •Connectivity
- •Telementoring
- •Education
- •Clinical Practice
- •Telesurgery
- •Robotic Surgical Platforms
- •Conclusion
- •References
- •Introduction
- •Foundational Knowledge
- •Practical Skills
- •Continuing Education
- •Conclusion
- •References
- •Robotic Surgery Curriculum
- •Surgical Decision-Making
- •Surgical Technique
- •Operative Technique
- •Facebook™ Groups
- •Conclusions
- •References
- •12: Robotic Paraesophageal Hernia Repair
- •Postoperative Care
- •References
- •Introduction
- •Pathophysiology
- •Clinical Features
- •Diagnosis
- •Endoscopic Functional Luminal Imaging Probe (EndoFLIP)
- •Treatment
- •Pharmacotherapy
- •Endoscopic Treatment
- •Botulinum Toxin Injection
- •Pneumatic Dilation
- •Per-oral Endoscopic Myotomy (POEM)
- •Heller Myotomy
- •Operative Steps
- •Liver Retraction
- •Hiatal Dissection
- •Myotomy
- •Partial Fundoplication
- •Intraoperative Complications
- •Esophageal Perforation
- •Gastric Perforation
- •Vagal Nerve Injury
- •Postoperative Care
- •References
- •14: Robotic Esophagectomy
- •Introduction
- •Robotic-Assisted Ivor-Lewis Esophagectomy
- •Abdominal Phase
- •Thoracic Phase
- •Robotic-Assisted McKeown Esophagectomy
- •Thoracic Phase
- •References
- •Introduction
- •Indications
- •Local Resection: “Wedge Gastrectomy”
- •Lymphadenectomy
- •Proximal Gastrectomy
- •Distal Gastrectomy
- •Total Gastrectomy
- •Reconstruction
- •Billroth I
- •Roux-en-Y
- •Double-Tract Reconstruction
- •Conclusion
- •References
- •16: Robotic Sleeve Gastrectomy
- •Introduction
- •Operative Technique
- •Conclusion
- •References
- •17: Robotic Roux-en-Y Gastric Bypass
- •Introduction
- •Indications
- •Contraindications
- •Patient Preparation
- •Technique (Key Operative Steps)
- •Complications
- •Early Complications
- •Late Complications
- •References
- •18: DS/SADI
- •Introduction
- •Patient Preparation
- •Surgical Technique
- •Single Anastomosis DuodenoIleal Bypass
- •Sleeve Gastrectomy
- •Bowel Measurement
- •Duodenal Dissection
- •Duodenoileostomy
- •Bowel Measurement
- •Enteroenterostomy
- •Postoperative Care
- •References
- •Introduction
- •Part I: Revisional Foregut Surgery
- •Introduction
- •Operative Principles: Robotic Revisional Foregut Surgery
- •Presurgical Care: Optimization/Prehabilitation
- •Operating Room Setup
- •Patient Positioning
- •Access/Port Placement/Liver Retraction
- •Fundoplication Takedown
- •Crural Repair
- •Mesh Reinforcement
- •Antireflux Procedure
- •Outcomes
- •Part II: Revisional Bariatric Surgery
- •Introduction
- •Preoperative Assessment
- •Setup
- •Access/Port Placement/Liver Retraction
- •Surgical Technique
- •Outcomes
- •References
- •20: Robotic Transabdominal Preperitoneal (TAPP) Inguinal Hernia Repair
- •Introduction
- •Preoperative Evaluation
- •Robotic TAPP
- •Instrumentation
- •Dissection
- •Mesh
- •Closure
- •Special Cases
- •Acute Presentation
- •Common Complications
- •Chronic Pain
- •Recurrence
- •Testicular Ischemia
- •Mesh Infection
- •Conclusion
- •References
- •Introduction
- •Preoperative Considerations
- •Intraoperative Considerations
- •R-TAPP
- •IPOM
- •Conclusion
- •References
- •22: Complex Robotic Abdominal Wall Reconstruction
- •Background
- •Preoperative Planning
- •Botox Injection
- •Patient Selection
- •Operative Procedure
- •Patient Positioning
- •Technique
- •Hybrid Robotic Ventral Hernia Repair
- •Conclusion
- •References
- •23: Robotic Cholecystectomy
- •Introduction
- •Indications
- •Robotic Dissection
- •Single-Port Robotic Cholecystectomy
- •References
- •Introduction
- •Robotic Liver Resection
- •Patient Selection
- •Positioning
- •Port Placement
- •Standard Robotic Instruments
- •Right Hepatectomy (see Video 1)
- •Falciform Dissection
- •Hilar Dissection
- •Intraoperative Ultrasound
- •Parenchymal Transection
- •Left Hepatectomy
- •Hilar Dissection
- •Pringle Maneuver
- •Left Lateral Sectionectomy
- •Right Posterior Sectionectomy
- •Segment 7 Resection
- •Segment 8 Resection
- •Robotic Biliary Reconstruction
- •Choledochal Cyst
- •Bile Duct Injury
- •Roux-en-Y Hepaticojejunostomy
- •Conclusion
- •References
- •25: Robotic-Assisted Pancreaticoduodenectomy (Whipple)
- •Robotic Whipple
- •Patient Selection
- •Operative Steps
- •Supra-pancreatic/Hilar Dissection
- •Uncinate Dissection
- •Reconstruction Phase
- •Final Steps
- •Vascular Resections
- •Postoperative Care
- •Conclusion
- •References
- •26: Right Hemicolectomy
- •Introduction
- •Indications
- •Preparation
- •Patient Positioning
- •Conclusion
- •References
- •Background
- •Indications
- •Operation Steps
- •Left Hemicolectomy
- •Total Colectomy
- •Learning Curve
- •Future Directions
- •Suprapubic Approach
- •Single-Site Robotic Surgery
- •da Vinci SP® Surgical System
- •Conclusion
- •References
- •28: Low Anterior Resection
- •Background
- •Learning Curve
- •Training Program
- •Genitourinary Function
- •Preoperative Planning
- •Operative Procedure
- •Room Setup
- •Patient Positioning
- •Technique
- •Conclusion
- •References
- •29: Robotic Lateral Transabdominal Adrenalectomy
- •Introduction
- •Pertinent Anatomy
- •Patient Positioning
- •Right Adrenalectomy
- •Port Placement
- •Technique
- •Left Adrenalectomy
- •Port Placement
- •Technique
- •Postoperative Care
- •Limitations
- •References
- •Introduction
- •Operative Room Setup
- •Patient Position
- •Surgical Procedure
- •Step 1: Working Space
- •Step 3: Console Time
- •Discussion
- •References
- •31: Robotic Pulmonary Lobectomy
- •Current Evidence
- •Surgical Technique
- •Right-Sided Resections
- •Right Upper Lobectomy
- •Right Lower Lobectomy
- •Right Middle Lobectomy
- •Left-Sided Resections
- •Left Lower Lobectomy
- •Conclusion
- •References
- •32: Robotic-Assisted Cardiac Surgery
- •Introduction
- •Robotic-Assisted Coronary Artery Bypass
- •Operative Technique
- •Outcomes
- •Robotic-Assisted TECAB
- •Hybrid Coronary Revascularization (HCR)
- •Robotic-Assisted Mitral Valve Surgery
- •Patient Selection
- •Outcomes
- •Robotic Aortic Valve Replacement
- •Conclusion
- •References
- •33: Mediastinal Procedures
- •Introduction
- •Anterior Mediastinal Mass Example Case Scenario
- •Anterior Mediastinal Mass Excision Operative Steps
- •Middle Mediastinal Mass Example Case Scenario
- •Middle Mediastinal Cyst Excision Operative Steps
- •Posterior Mediastinal Mass Case Scenario
- •Patient Positioning
- •Posterior Mediastinal Mass Excision Operative Steps
- •Summary
- •References
- •34: Liver Transplantation
- •Introduction
- •Robotic Donor Hepatectomy
- •Patient Selection
- •Positioning
- •Port Placement
- •Instruments
- •Adjunct Robotic Instruments
- •Right Donor Hepatectomy
- •Falciform Dissection
- •Hilar Dissection
- •Demarcation
- •Parenchymal Transection
- •“Rubber Band” Retraction Technique
- •Parenchymal Transection
- •Closure
- •Left Donor Hepatectomy
- •Hilar Dissection
- •Demarcation
- •Parenchymal Transection
- •“Rubber Band” Retraction Technique
- •Parenchymal Transection

5 Versius Surgical Robot
Fig. 5.9 Instrument and visualization bedside units
Fig. 5.10 The Versius
instrument bedside unit
51

52
Fig. 5.11 Bedside unit in
sleep mode
S. Khanna and A. Barua
Arm Modes
Versius arm has seven modes (Fig.5.12). These modes can be shifted from one
mode to another with the help of elbow and V-Wrist buttons placed at the instrument
bedside units. These are described in the gure below.
To put the surgical arm from locked to surgical mode, the V-Wrist button is used.
The sequence of modes that the arm goes though is depicted in the arm mode map
below (Fig.5.13).
1. Sleep mode: In this mode, the arm is in compact storage position, and one needs
to awaken the arm by pressing the sleep button to make further use of the same.
2. Locked mode: In this mode, only the distal end of the bedside unit can be
moved. The rest of the arm stays in position to facilitate attaching the instrument
to the arm before port training.
3. Unlocked mode: Unlocked mode is used when the bedside team needs to freely
move and position the arm, for example, during positioning for draping and positioning the arm into an arc before port training.
4. Port training mode: This mode trains the surgical robot so that it knows the
location of the pivot around the fulcrum, on which the instruments and endoscope move. This pivot point is located on air, at that specied three-dimensional
axis, so that the abdominal wall does not need to be the pivot point as in laparoscopy. This decreases the pain signicantly since the trauma to the abdominal
wall at the port sites is much lesser.
5. Instrument adjust mode: The instrument can be advanced in this mode inside the
patient cavity once the port training is complete. The arm can be manually moved
with complete freedom of movement while respecting the fulcrum position.

5 Versius Surgical Robot
Fig. 5.12 Arm mode icons for a pink arm
53
Fig. 5.13 Versius arm mode map showing the use of V-Wrist and elbow buttons to put the arm in
various modes

54
Fig. 5.14 Arm clash icon
for a pink arm
S. Khanna and A. Barua
6. Surgical mode: In this mode, the surgeon can manipulate the endoscopic cam-
era and the instruments using the hand controllers on the surgeon console.
7. Instrument change mode: This mode is used to change an instrument or endo-
scope. The arm respects the fulcrum and the arm’s motion is restrained by the
system, so that the arm and instrument or endoscope can only be moved in a
straight line along the axis of the instrument. In this mode, the system remembers the instrument position upon entering instrument change mode and prevents
movement deeper into the patient cavity.
Arm Clash
This robot, having multiple independent arms, has a possibility of frequent clashes
if not placed optimally. A Versius arm detects an arm clash if it is pushed too hard
by a user pushing or by the arm colliding with an object. If an arm clash occurs, an
arm clash icon appears in the icon group of the affected bedside unit (Fig.5.14).
To resolve thearm clash
• If the clash was from manual pushing, let go of the arm.
• If the clash was from a collision, manually move the arm away from the object
in instrument adjust mode.
Instrument Compatibility, User Interface, andErgonomics
It has all the standard instruments like monopolar hook, monopolar curved
scissor, bipolar Maryland grasper, cold scissor, fenestrated graspers, and needle holder, all with a wristed tip. The instruments are attached to the distal end

5 Versius Surgical Robot
55
of an instrument arm after the arm drape has been fitted. Each instrument type
has the same attachment head and a shaft of 6.8mm diameter. The attachment
head has latches for attaching the instrument to the arm, and fins, which
mechanically drive the instrument during surgery. The distal joint can rotate
720° on its own axis for greater maneuverability. The endoscopes have a 10mm
diameter shaft and a 300 mm working length. It comes with 0-degree and
30-degree scopes, which can be attached 30° up or 30° down. It can be moved
up–down and left–right. It provides an 81.1° of view. The magnification is 15x
with 3D high-definition vision (3DHD). The surgeon needs to put on polarizing
3D glasses for 3D visualization. The head-up display has the option of visualizing in 2D vision also if the surgeon desires so. The visualization unit needs
an 11mm port, while all the instrument ports are 5mm. Applied Medical balloon ports are one among the validated ports for use with the 10mm robotic
endoscope and 5mm wristed instruments. Inappropriate port size could lead to
an incorrect fulcrum being detected during port training. One of the biggest
advantages of this system is that the laparoscopic port placement can be replicated for any surgery and a distance of min 5–6cm from each port is enough to
avoid arm clash. Post training of the arm, the instrument tip has to be a min of
2cm intracorporeally to start functioning. Apart from the robotic ports, standard laparoscopic ports can be used by the assistant surgeon for additional
retraction, suction, mopping with gauze, use of staplers, use of choledochoscope, etc. The assistant surgeon can shift the elbow of the robotic arm without
disturbing the intracorporeal position of the instrument and fit in at any position for putting up a port and assistance, with minimal risk of injury to the
assistant surgeon due to extracorporeal movement of the instrument arms. In
contrast to laparoscopic surgeries, where the standard laparoscopic endoscope
needs to be repeatedly cleaned and dipped in hot water to avoid fogging, the
problem of fogging of the robotic camera lens is virtually nonexistent due to
constant smoke evacuation and achieving the desired electrocautery effect at
very low-level settings. Although the Versius Surgical System was validated
using a Wolf Endo light system, the light sources of various other companies
are compatible. The instruments can be used multiple times, and the life of
each instrument varies. All instruments are supplied nonsterile and must be
cleaned and steam sterilized before each use. The Versius robotic system
requires an Internet connection with an average upload bandwidth of up to
2Mbps for use in analyzing and improving Versius, and analyzing and improving minimal access surgical techniques. This data is uploaded using a wired
Ethernet connection to the Internet. Versius will function normally if there is
no connection to the Internet, but data will not be uploaded. This system is
indicated for adult use only. The Versius Surgical System requires no routine
adjustments to maintain operation and must be serviced only by CMR Surgical
or by an appointed agent (Figs.5.15, 5.16, and 5.17).

56
Fig. 5.15 Versius instruments
S. Khanna and A. Barua
Fig. 5.16 Endoscopic camera
Fig. 5.17 Endoscope
angled (30°) and
straight (0°)
Bedside Unit Positioning Around theOperating Table
The position of the bedside units (BSUs) varies according to the surgical procedure
being planned, which again depends on what anatomical region the arms need to
reach. They should always be placed parallel to the operating table, with the brake

5 Versius Surgical Robot
Fig. 5.18 Position of the
BSU parallel to the
operating table
57
button away from the table. A maximum of three instrument bedside units can be
used along with a visualization bedside unit with the Versius system. The BSUs can
be placed close to each other, taking care that the V-Wrists are adequately separated,
so that they do not clash on movement during the surgery (Figs.5.18 and 5.19). The
BSUs should be placed so that
• The V-Wrist is not too close to other arms.
• The V-Wrist will not clash with the base.
• The arm does not need to extend any joints fully.

58
S. Khanna and A. Barua
Fig. 5.19 Example of Versius system with four bedside units layout
System Connections
Surgeon console connection panel Located on the base of the surgeon console at
the rear, the connection panel is where all the cables are connected to the surgeon
console (Fig.5.20).

5 Versius Surgical Robot
Fig. 5.20 Surgeon console connection panel
59
Fig. 5.21 Cart connection panels
The cables connected to the surgeon console are
• Surgeon console power cable (nonsterile)
• Network cable (nonsterile)
• Auxiliary screen cable (nonsterile)
• Video feed cable (nonsterile)
• Bedside unit cable(s) (nonsterile)
Connecting aBedside Unit totheSystem
The power-in and power-out sockets available on a cart connection panel are used
to connect a bedside unit to either the surgeon console or another bedside unit,
based on the system conguration (cabling scheme) chosen: “spider,” “daisy chain,”
or “hybrid” (Figs.5.21 and 5.22).

60
S. Khanna and A. Barua
Fig. 5.22 The system cabling congurations
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