3. ENDOSCOPIC SURGERY DISADVANTAGES UNNATURAL OPERATIVE FEEL 2-D VISION, HANDS AND INSTRUMENTS MISALIGNED LIMITED DEXTERITY INSIDE PATIENTS HANDS/WRIST OUTSIDE PATIENT FIXED INSTRUMENTS TIPS INSIDE PATIENT LONG INSTRUMENTS, INVERTED MOVEMENT ONLY 4 DOF + GRIP

4. COMPUTER-ENHANCED SURGERY INCREASED DEXTERITY AND PRECISION (6 DOF + GRIP) IMPROVED INTRA-CAVITARY RANGE OF MOTION VISUAL IMMERSION INTUITIVE MOTION (ANTHROPOMORPHIC CONCEPT) SCALING FILTERING TELESURGICAL PERFORMANCE ENHANCEMENT OF ENDOSCOPIC SURGICAL TECHNIQUE THROUGH:

5. BASIC ORGANIZATIONAL CRITERIA STANDARDIZATION OF THE SURGICAL PROCEDURES INSTALLATION OF ROBOTIC SYSTEM AND PLANING THE DISPOSITION OF THE OPERATING ROOM TRAINING OF SURGICAL TEAM ORGANIZATION OF THE WARD QUALITY CONTROL

6. STANDARDIZATION OF THE SURGICAL PROCEDURES IT IS NECESSARY TO PERFORM IN A SAFE AND STRAIGHTFORWARD MANNER AN AND STRAIGHTFORWARD MANNER AN EXTREMELY ADVANCED AND INNOVATIVE MODALITY LIKE ROBOTIC SURGERY, WHERE THE DETAILS TO ATTEND TO ARE A GREAT MANY.

7. TRAINING OF THE SURGICAL TEAM SCRUB NURSES TECHNICIANS SURGEONS ANESTHESIOLOGIST

8. TRAINING OF THE SURGICAL TEAM ROOM PERSONNEL (SCRUB NURSES, TECHNICIANS) IT ALLOW THE CREATION OF A TEAM ABLE TO ACTIVATE AND MAINTAIN THE ENTIRE OPERATIVE SYSTEM, TAKE CHARGE AND HANDLING ALL MATERIALS AND INSTRUMENTS APPROXIMATELY 15 DAYS ARE NECESSARY TO COMPLETE ADEQUATE TRAINING OF PERSONNEL GIULIANOTTI, OSP. ITAL. CHIR., 2001

9. TRAINING OF THE SURGICAL TEAM ROOM PERSONNEL SETUP OF ROBOTIC SYSTEM Connection of the console to the robotic cart electric cables and optic fibers and optic fibers System switch-on System switch-on Self-test Self-test Draping of the robotic arms with insertion of electronic Draping of the robotic arms with insertion of electronic microcircuit plates microcircuit plates Fixing of mechanical supports for trocars on the robotic arms Fixing of mechanical supports for trocars on the robotic arms SETUP OF OPTIC SYSTEM ON THE CONSOLE Frontal or inclined position of the scope (0° - 30°) White balancing White balancing Setting of the 2-D or 3-D vision Setting of the 2-D or 3-D vision Vision centering for the monitor of the console Vision centering for the monitor of the console

10. TRAINING OF THE SURGICAL TEAM ASSISTANCE ON THE SURGICAL FIELD INITIAL PHASE OF THE PROCEDURE Patient positioning Patient positioning Induction of pneumoperitoneum Induction of pneumoperitoneum Placement of trocars Placement of trocars Initial phase of surgical intervention (conventional VL) Initial phase of surgical intervention (conventional VL) Robot cart positioning Robot cart positioning Introduction/extraction of the robotic surgical instruments Introduction/extraction of the robotic surgical instruments

11. TRAINING OF THE SURGICAL TEAM ASSISTANCE ON THE SURGICAL FIELD SURGICAL PROCEDURE Placement of trocars Placement of trocars Divarication and exposure of operative field Introduction of materials in operative field (stitches, needles, gauzes, Introduction of materials in operative field (stitches, needles, gauzes, prostheses, endobags) prostheses, endobags) Use of accessory instruments (clips, staplers, loops) Use of accessory instruments (clips, staplers, loops)

12. TRAINING OF THE SURGICAL TEAM ASSISTANCE ON THE SURGICAL FIELD FINAL PHASE OF THE SURGICAL PROCEDURE Extraction of operative specimens Exploration of operative field Introduction of drain tube Extraction of the trocars Desufflaction Removal of robotic station from patient First assistance in case of immediate conversion

13. QUALITY CONTROL EVALUATION MUST BE CRITICAL AND AIMED AT INCREASING EFFICENCY, OPTIMIZING AVAILABLE INCREASING EFFICENCY, OPTIMIZING AVAILABLE RESOURCES AND POSSIBLY LOWERING COSTS RESOURCES AND POSSIBLY LOWERING COSTS THE MOST SIGNIFICANT INDICATORS ARE: - OPERATIVE TIME - OPERATIVE TIME - RATE OF CONVERSION - RATE OF CONVERSION - MORBIDITY - MORBIDITY - LENGTH OF HOSPITAL STAY - LENGTH OF HOSPITAL STAY

14. ROBOTIC SURGERY CENTER CLINICAL PRACTICE DIDACTIC ACTIVITY DIDACTIC ACTIVITY RESEARCH RESEARCH

15. LEARNING CURVE SURGEONS FAMILIARITIATION WITH FOLLOWING ASPECTS: BINOCULAR AND THREE-DIMENSIONAL VISION BINOCULAR AND THREE-DIMENSIONAL VISION RESTRICTED OPERATIVE FIELD RESTRICTED OPERATIVE FIELD THE HANDLING OF JOYSTICKS THE HANDLING OF JOYSTICKS ROBOTIC SURCICAL INSTRUMENTS ROBOTIC SURCICAL INSTRUMENTS MOVEMENTS OF ROBOTIC ARMS AND OF SURCICAL INSTRUMENTS MOVEMENTS OF ROBOTIC ARMS AND OF SURCICAL INSTRUMENTS (CONPUTERED TREMOR REDUCTION, WRISTED INSTRUMENTS) ABSENCE OF TACTILE FEEDBACK

16. LEARNING CURVE 1. THEORETICAL PHASE 2. TRAINING AT THE CONSOLE (MECHANICAL OR ANIMALS MODELS) 3. KNOWLEDGE OF THE TECHNICAL ASPECTS OF THE ROBOTIC SYSTEM, OF PROCEDURES FOR INSTALLING THE ROBOT ON OPERATING FIELD, OF HANDLING OF SURGICAL INSTRUMENTS 4. CLINICAL APPLICATION (VL COLECISTECTOMY WITH TUTORING)

17. 20 PROCEDURES ARE NECESSARY TO COMPLETE THE LEARNING CURVE FOR THIS PROCEDURE FIRTS 20 PATIENTS 38 PATIENTS MEDIAN OPERATIVE TIME: 103.5 min 75.2 min RANGE (50 – 210) (30 – 120) T Student p = 0.002 LEARNING CURVE IN ROBOTIC COLECISTECTOMY GIULIANOTTI, 2001

18. HANCE J ET AL: J MEDICAL ROBOTICS AND COMPUTER ASSISTED SURGERY, 2005 CRITERIA FOR EVALUATING ROBOTIC LEARNING CURVE MAIN PROBLEMS STANDARDISATION OF PATIENTS STANDARDISATION OF PATIENTS LACK OF METHODS TO OBJECTIVELY ASSESS PERFORMANCE LACK OF METHODS TO OBJECTIVELY ASSESS PERFORMANCE THE MAJORITY OF STUDIES HAVE FOCUSED UPON DRY LAB EXPERIMENTS THE MAJORITY OF STUDIES HAVE FOCUSED UPON DRY LAB EXPERIMENTS HANCE J ET AL: J MEDICAL ROBOTICS AND COMPUTER ASSISTED SURGERY, 2005

19. CRITERIA FOR EVALUATING ROBOTIC LEARNING CURVE MAIN QUESTIONS DOES THE ROBOTIC LEARNING CURVE PLATEAU? DOES THE ROBOTIC LEARNING CURVE PLATEAU?AND DOES PREVIOUS LAPAROSCOPIC EXPERIENCE LEAD TO DOES PREVIOUS LAPAROSCOPIC EXPERIENCE LEAD TO FASTER ACQUISITION OF TELEROBOTIC SKILLS? FASTER ACQUISITION OF TELEROBOTIC SKILLS? HANCE J ET AL: J MEDICAL ROBOTICS AND COMPUTER ASSISTED SURGERY, 2005

20. METHODS 13 SURGEONS COMPLETED FIVE SYNTHETIC SMALL BOWEL ANASTOMOSES USING THE DA VINCI SYSTEM OBJECTIVE STRUCTURED ASSESMENT OF TECHNICAL SKILLS (OSATS) ALLOWED QUALITATIVE ANALYSIS THE API (APPLICATION PROGRAMMING INTERFACE) SOFTWARE USED TO RETRIEVE REAL-TIME ROBOTIC SIGNAL DATA OF TIME, PATH LENGTH AND NUMBER OF MOVEMENTS (P VALUE < 0.05 WAS CONSIDERED SIGNIFICANT) HERNANDEZ ET AL: SURG ENDOSC, 2004 QUALITATIVE AND QUANTITATIVE ANALYSIS OF THE LEARNING CURVE OF A SIMULATED SURGICAL TASK ON THE DA VINCI SYSTEM

21. RESULTS HERNANDEZ ET AL: SURG ENDOSC, 2004 QUALITATIVE AND QUANTITATIVE ANALYSIS OF THE LEARNING CURVE OF A SIMULATED SURGICAL TASK ON THE DA VINCI SYSTEM FIRST ATTEMP FIFTH ATTEMP p OSATS GLOBAL SCORE POINTS 18.6260.02 TIME (SEC.) 3507 350722870.008 TOTAL NUMBER OF MOVEMENTS 2411 241113870.01 TOTAL PATH LENGTH (CM) 21,630 21,63013,9410.01

22. ROBOTIC SURGERY: IDENTIFYING THE LEARNING CURVE THROUGH OBJECTIVE MEASUREMENT OF SKILL CHANG L ET AL: SURG ENDOSC, 2003 METHODS 8 SURGEONS PERFORMED INTACORPOREAL KNOT TYING TASKS BEFORE AND 8 SURGEONS PERFORMED INTACORPOREAL KNOT TYING TASKS BEFORE AND AFTER 3 WEEK SURGICAL ROBOTIC TRAINING AFTER 3 WEEK SURGICAL ROBOTIC TRAINING THESE PERFORMANCE WERE COMPARED TO THEIR LAPAROSCOPIC THESE PERFORMANCE WERE COMPARED TO THEIR LAPAROSCOPIC KNOTS AND ANALYZED TO DETERMINE AND DEFINE SKILL IMPROVEMENT KNOTS AND ANALYZED TO DETERMINE AND DEFINE SKILL IMPROVEMENT

23. ROBOTIC SURGERY: IDENTIFYING THE LEARNING CURVE THROUGH OBJECTIVE MEASUREMENT OF SKILL CHANG L ET AL: SURG ENDOSC, 2003 RESULTS LAPAROSCOPY ROBOTIC SURGERY AFTER 4-6 HOURS OF ROBOTIC TRAINIG TIME (SEC.) 140 (M.C.: 77) 390 (M.C.: 40) 139 (M.C.: 71)

24. LEARNING CURVE MAY PLATEAU SOONER FOR ROBOTIC MANIPULATIONS WHEN COMPARED TO MANUAL LAPAROSCOPY MANIPULATIONS WHEN COMPARED TO MANUAL LAPAROSCOPY PREVIOUS EXPOSURE TO LAPAROSCOPY ENABLES A SURGEON TO PREVIOUS EXPOSURE TO LAPAROSCOPY ENABLES A SURGEON TO INCORPORATE ROBOTICS MORE RAPIDLY THAN A SURGEON WITH INCORPORATE ROBOTICS MORE RAPIDLY THAN A SURGEON WITH NON PREVIOUS KNOWLEDGE OF MINIMAL INVASIVE SURGERY NON PREVIOUS KNOWLEDGE OF MINIMAL INVASIVE SURGERY HOWEVER IT IS DIFFICULT TO ESTABLISH GUIDELINES FOR HOWEVER IT IS DIFFICULT TO ESTABLISH GUIDELINES FOR CLINICAL TRAINING SOLELY FROM THIS DRY-LAB DATA CLINICAL TRAINING SOLELY FROM THIS DRY-LAB DATA HANCE J ET AL: J MEDICAL ROBOTICS AND COMPUTER ASSISTED SURGERY, 2005

27. RISULTATI PROCEDURE: 43 DEGENZA MEDIA: 48.6 h MORTALITA: 0 MORBILITA: 3 - OCCLUSIONE INTESTINALE: 1 - OCCLUSIONE INTESTINALE: 1 - EMORRAGIA SITO TROCAR ACCESSORIO: 2 - EMORRAGIA SITO TROCAR ACCESSORIO: 2

28. IT IS NECESSARY TO STANDARDIZE PROCEDURES AND ESTABLISH IT IS NECESSARY TO STANDARDIZE PROCEDURES AND ESTABLISH OPERATIVE SCHEMES AND TRAINING PROTOCOLS FOR THIS THECNOLOGY OPERATIVE SCHEMES AND TRAINING PROTOCOLS FOR THIS THECNOLOGY ADEQUATE TRAINING WILL ALLOW THE CREATION OF SURGICAL TEAM ADEQUATE TRAINING WILL ALLOW THE CREATION OF SURGICAL TEAM (SURGEONS, ANESTHESIOLOGISTS, OPERATING ROOM PERSONNEL) ABLE (SURGEONS, ANESTHESIOLOGISTS, OPERATING ROOM PERSONNEL) ABLE TO ACTIVATE AND MANTEIN THE ENTIRE OPERATIVE SYSTEM AND TO TO ACTIVATE AND MANTEIN THE ENTIRE OPERATIVE SYSTEM AND TO APPLIE THE ROBOTIC THECHNIQUE IN MANY SUIRGICAL PROCEDURES APPLIE THE ROBOTIC THECHNIQUE IN MANY SUIRGICAL PROCEDURES TRAINING MUST BE DEDICATED TO SURGEONS WITH PREVIOUS TRAINING MUST BE DEDICATED TO SURGEONS WITH PREVIOUS KNOWLEDGE OF CONVENTIONAL AND MINIMAL INVASIVE SURGERY KNOWLEDGE OF CONVENTIONAL AND MINIMAL INVASIVE SURGERY CONCLUSIONS

29. FUTURE TRAINING VIRTUAL REALITY SIMULATOR VIRTUAL REALITY SIMULATOR - www.simsurgery.com (Norway) - www.simsurgery.com (Norway) www.simsurgery.com - Two Handed Universal Master Console (THUMP) - Two Handed Universal Master Console (THUMP) TELEMENTORING TELEMENTORING ENHANCEMENT OF SURGEONS VIEW ENHANCEMENT OF SURGEONS VIEW - Simulation and Transfer Architecture for Robotic Surgery (STARS) - Simulation and Transfer Architecture for Robotic Surgery (STARS)

30. FUTURE TRAINING HIGH TECHNOLOGY FORMATION HIGH TECHNOLOGY FORMATION MEDICAL LEGAL IMPLICATIONS MEDICAL LEGAL IMPLICATIONS