title: Does robotic assistance improve efficiency in performing complex minimally invasive surgical procedures?
abstract: OBJECTIVE
  We used a model of biliary-enteric anastomosis to test whether da Vinci robotics improves performance on a complex minimally invasive surgical (MIS) procedure.
  
  
  METHODS
  An ex vivo model for choledochojejunostomy was created using porcine livers with extrahepatic bile ducts and contiguous intestines. MIS choledochojejunostomies were performed in two arms: group 1 (laparoscopic, n = 30) and group 2 (da Vinci assisted, n = 30). Procedures were performed by three surgeons with graduated MIS expertise: surgeon A (MIS + robotics), surgeon B (experienced MIS), and surgeon C (basic MIS). Each surgeon performed ten procedures per group. The primary objective was time to complete anastomoses using each method. Secondary objectives included anastomosis quality, impact of experience on performance, and learning curve.
  
  
  RESULTS
  da Vinci led to faster anastomoses than laparoscopy (28.0 vs. 35.9 min, p = 0.002). Surgeon A's mean operative times were equivalent with both techniques (24.5 vs. 22.3 min). Surgeons B and C experienced faster operative times with robotics over laparoscopy alone (39.4 vs. 28.6 min, p = 0.01; and 43.8 vs. 33.0 min, p = 0.008, respectively). Surgeon A did not demonstrate a learning curve with either laparoscopy (22.4 vs. 22.4 min, p = not significant, NS) or robotics (24.7 vs. 19.8 min, p = NS). Surgeon B demonstrated nonsignificant improvement with laparoscopy (46.6 vs. 39.5 min, p = NS). With robotic assistance, a learning curve was demonstrated (36.8 vs. 24.7 min, p = 0.02). Surgeon C demonstrated a learning curve with laparoscopy (58.3 vs. 33.2 min, p = 0.004), but no improvement was noted with robot assistance (32.2 vs. 34.7 min, p = NS).
  
  
  CONCLUSIONS
  da Vinci improves time to completion and quality of choledochojejunostomy over laparoscopy in an ex vivo bench model. This advantage is more pronounced in the hands of surgeons with less MIS experience. Conversely, robotics may allow less experienced surgeons to perform more complex operations without first developing advanced laparoscopic skills; however, there may be benefit to first obtaining fundamental skills.
authors.affiliation: CSTAR (Canadian Surgical Technologies and Advanced Robotics), Lawson Health Research Institute, London, ON, Canada. shivaj76@yahoo.ca
authors.forename: Shiva
authors.initials: S
authors.lastname: Jayaraman
authors.forename: Douglas
authors.initials: D
authors.lastname: Quan
authors.forename: Ibrahim
authors.initials: I
authors.lastname: Al-Ghamdi
authors.forename: Firas
authors.initials: F
authors.lastname: El-Deen
authors.forename: Christopher M
authors.initials: CM
authors.lastname: Schlachta
mesh_terms: D000714:Anastomosis, Surgical / Q000295:instrumentation*; D000818:Animals; D002768:Choledochostomy / Q000295:instrumentation*; D004526:Efficiency; D010535:Laparoscopy / Q000379:methods; D008099:Liver / Q000601:surgery*; D019060:Minimally Invasive Surgical Procedures / Q000295:instrumentation*; D012371:Robotics / Q000295:instrumentation*; D013552:Swine; D013997:Time Factors