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Robot-assisted radical prostatectomy (RARP) has gained prominence since the da Vinci surgical system was introduced in 2000. RARP has now become a standard procedure for treating cases with localized prostate cancer. However, no study has examined its surgical time by accurately measuring the pelvic visceral fat (PVF) volume. This study aimed to investigate the factors associated with prolonged console time and surgical difficulty by RARP surgeons. This study included 405 patients who underwent RARP between 2014 and 2019 at our institution. Given that the anatomical characteristics were considered to affect RARP, PVF and working space (WS) were estimated preoperatively by computed tomography using a 3D image analysis system. Univariate and multivariate logistic regression analyses were performed to identify the factors prolonging console time, such as body mass index (BMI), prostate volume, previous abdominal surgery, nerve-sparing procedure, PVF, and WS. We also investigated whether post-operative complications were associated with any of these factors. Larger PVF (p = 0.028, odds ratio (OR) 1.43), smaller WS (p

Aim of the study was to present the surgical techniques and the postoperative outcomes in women treated with robotic excision for deep endometriosis involving the urinary tract. We retrospectively reviewed the prospectively recorded clinical data of women consecutively undergoing minimally invasive treatment for complex endometriosis involving urinary tract in our center between January 2012 and June 2018. All the patients received a preoperative multidisciplinary evaluation with the general surgeon, the gynecologist and the urologist due to the frequent concomitant involvement of bowel and genital system. Patients undergoing robotic surgery were treated with the Si or Xi da Vinci surgical system. A total of 74 consecutive patients were enrolled. Twenty-eight (37.8%) patients underwent conventional laparoscopy and 46 (62.2%) robotic surgery. Only patients treated with robotic approach were considered for the final analyses. Overall, 17 (36.9%) patients were treated with partial cystectomy, 13 (28.3%) with ureteral reimplantation, 10 (21.7%) patients were treated with ureteral lysis, 4 (8.7%) with removal of bladder endometrial node without opening the mucosa layer and 2 (4.3%) with ureteral end-to-end anastomosis. Concomitant involvement of bowel and genital system was registered in 14 (30.4%) and 32 (69.5%) patients, respectively. No conversions to laparotomy were recorded. Overall, 5 (10.9%) patients experienced postoperative complications, of which only one was a major complication (Clavien 3b). At a median follow-up of 31.3 (IQR 17.6–43.3) months, 4 (8.7%) patients experienced disease recurrence at the level of urinary tract. Robotic excision of urological endometriosis represents a safe and effective treatment option, since a limited rate of surgical complications was recorded even in cases of multi-organ disease.

The main treatment of choledochal cysts is the complete resection of the cyst with Roux-en-Y hepaticojejunostomy, which includes open procedures, laparoscopic procedures, and robot-assisted procedures using a da Vinci surgical system. The aim of this current study was to investigate the safety and effectiveness of these three different surgical methods in pediatric choledochal cyst excisions. Between January 2015 and December 2018, patients with choledochal cysts treated with open procedures, laparoscopic procedures, or robot-assisted procedures were retrospectively analyzed. The data collected included demographic information of all patients, type and size of cyst, operative details, and postoperative outcomes. A total of 371 episodes of patients were enrolled which consist of the open procedures group (n = 226), laparoscopic procedures group (n = 104), and robot-assisted procedures group (n = 41). The operation time was significantly longer in the laparoscopic procedures group (212.79 ± 34.94) than open procedures group (115.88 ± 13.50) and robot-assisted procedures group (180.61 ± 14.07) (p

Sigmoid colon cancer is a lethal disease and has a strong indication for surgery. Robotic-assisted surgery is one of the promising alternative treatment for this disease. Nowadays, the MicroHand S surgical system and the Da Vinci surgical system have been assembled in China. However, there is still no report to study the therapeutic effects of the two robotic-assisted surgical systems. Thus, the purpose of this study was to compare clinical and economic outcomes of patients with sigmoid colon cancer undergoing robot-assisted radical surgery via The MicroHand S or Da Vinci surgical system. The clinical data of 45 patients with sigmoid colon cancer undergoing the MicroHand S or Da Vinci robotic-assisted surgery at The Third Xiangya Hospital of Central South University from January 2017 to January 2019 were retrospectively analyzed. Twenty-one patients received MicroHand S robotic-assisted radical surgery and 24 patients received Da Vinci robot-assisted radical surgery. No significant differences were observed in terms of operation time, number of lymph node harvested, blood loss, intestinal exhaust time, time of oral feeding resumption, volume of abdominal cavity 24-h drainage, hospital stay, complication and rate of conversion, removal time of drainage tube and catheter between MicroHand S and Da Vinci group. However, the MicroHand S group had significantly lower hospitalization costs (P = 0.002) and shorter time to get out of bed after surgery (P = 0.04). In addition, no recurrence and metastases were observed in both groups during the follow-up. In patients with sigmoid colon cancer, the Da Vinci surgical system did not show obvious clinical advantages compared to the MicroHand S surgical system in surgical outcomes. However, the MicroHand S surgical platform showed advantages in terms of the hospitalization costs and length of postoperative bedtime. The outcome of this study will probably result in a shift to the MicroHand S surgical system as treatment preference in China.

Background Effective visualization of the operative field is vital to surgical safety and education. However, additional metrics for visualization are needed to complement other common measures of surgeon proficiency, such as time or errors. Unlike other surgical modalities, robot-assisted minimally invasive surgery (RAMIS) enables data-driven feedback to trainees through measurement of camera adjustments. The purpose of this study was to validate and quantify the importance of novel camera metrics during RAMIS. Methods New (n = 18), intermediate (n = 8), and experienced (n = 13) surgeons completed 25 virtual reality simulation exercises on the da Vinci Surgical System. Three camera metrics were computed for all exercises and compared to conventional efficiency measures. Results Both camera metrics and efficiency metrics showed construct validity (p

Robotic thyroid surgery using the da Vinci surgical system has certain cosmetic advantages; however, the invasiveness of robotic thyroid surgery is still a concern to many surgeons. Previous research has not directly compared the surgical stress of robotic thyroidectomy with that of conventional open surgery. The aim of the present study was to evaluate surgical stress using postsurgical measurements of several clinical markers. A pilot study was performed to evaluate surgical stress following robotic and open thyroid surgery. A total of 29 papillary thyroid cancer patients from July to November 2014 were enrolled. Fourteen patients underwent conventional open surgery, and fifteen underwent robotic thyroidectomy. IL-6 levels, serum WBC counts, CRP levels, surgical plethysmographic index (SPI), and visual analogue scale (VAS) score were measured to compare surgical stress between the robotic and the open surgery groups. No significant differences were seen between the two groups in IL-6 level, WBC count or CRP level (p = 0.380, 0.374, 0.360, respectively). Mean SPI level during the surgery was 41.9 ± 4.7 in open group compared to 39.5 ± 2.2 in robotic group, though this finding showed borderline significance (p = 0.095). VAS score after open surgery was significantly higher than after robotic operation (p = 0.048). The results of this study suggest that robotic thyroidectomy can result in a less than equivocal systemic stress response than is seen in open thyroidectomy. However, further investigation including large-scale, prospective, multicenter studies is warranted for non-inferiority trials.

Background The aim of this study was to enhance the visual feedback of surgeons, during robotic surgeries, by designing and developing an actuated 2D imaging probe, which is used in conjunction with the traditional stereoscopic camera of the da Vinci surgical system. The probe provides the surgeon with additional visual cues, overcoming visualization constraints encountered during certain scenarios of robot-assisted minimally invasive surgery. Methods The actuated imaging probe is implemented as a master–slave tele-manipulated system, and it is designed to be compatible with the da Vinci surgical system. The detachable probe design enables it to be mounted on any of the EndoWrist® instruments of the robot and is controlled by the surgeon using a custom-made pedal system. The image from the 2D probe is rendered along with the stereoscopic view on the surgeon’s console. Results The experimental results demonstrate the effectiveness of the proposed actuated imaging probe when used as an additional visualization channel and in surgical scenarios presenting visual problems due to tissue occlusion. Conclusion The study shows the potential benefits of an additional actuated imaging probe when used in conjunction with traditional surgical instruments to perform surgical tasks requiring visualization from multiple orientations and workspaces. Acknowledgments This work was partially supported by the National Priorities Research Program (NPRP) under Grant NPRP 09-776-2-298 from the Qatar National Research Fund (a member of Qatar Foundation). The statements made herein are solely the responsibility of the authors. We would like to thank Dr. Jean-Marc Peyrat for his assistance in the experiments. Scopus

The use of laparoscopic and robotic procedures has increased in general surgery. Minimally invasive robotic surgery has made tremendous progress in a relatively short period of time, realizing improvements for both the patient and surgeon. This has led to an increase in the use and development of robotic devices and platforms for general surgery. The purpose of this review is to explore current and emerging surgical robotic technologies in a growing and dynamic environment of research and development. This review explores medical and surgical robotic endoscopic surgery and peripheral technologies currently available or in development. The devices discussed here are specific to general surgery, including laparoscopy, colonoscopy, esophagogastroduodenoscopy, and thoracoscopy. Benefits and limitations of each technology were identified and applicable future directions were described. A number of FDA-approved devices and platforms for robotic surgery were reviewed, including the da Vinci Surgical System, Sensei X Robotic Catheter System, FreeHand 1.2, invendoscopy E200 system, Flex® Robotic System, Senhance, ARES, the Single-Port Instrument Delivery Extended Research (SPIDER), and the NeoGuide Colonoscope. Additionally, platforms were reviewed which have not yet obtained FDA approval including MiroSurge, ViaCath System, SPORT™ Surgical System, SurgiBot, Versius Robotic System, Master and Slave Transluminal Endoscopic Robot, Verb Surgical, Miniature In Vivo Robot, and the Einstein Surgical Robot. The use and demand for robotic medical and surgical platforms is increasing and new technologies are continually being developed. New technologies are increasingly implemented to improve on the capabilities of previously established systems. Future studies are needed to further evaluate the strengths and weaknesses of each robotic surgical device and platform in the operating suite.

Simple enucleation (SE) has proven to be oncologically safe. We describe the surgical steps and report the results of the Endoscopic Robotic-Assisted Simple Enucleation (ERASE) technique. Data were gathered prospectively from 130 consecutive patients undergone ERASE for intracapsular kidney cancer, between 2010 and 2013. ERASE was performed using the 4S Da Vinci surgical system, (Intuitive Surgical, Sunnyvale, CA, USA) in a three-arm configuration. Patients’ characteristics and surgical outcomes of ERASE in cT1 were analyzed and the results in cT1a tumors were compared to those of pure laparoscopic SE performed in the same institution in the same time period. The mean (range) preoperative tumor size was 3.2 cm (0.8–10.0 cm), and clinical stage was T1a for 101 patients, T1b for 28, and T2a for 1. Median PADUA score was 8 (IQR 7–9). In 33.9 % of patients, ERASE was done without pedicle clamping. Mean (±SD) warm ischemia time (WIT) was 18 ± 6 min. According to Clavien system, 1 grade 1 (0.8 %), 5 grade 2 (3.1 %), 4 grade 3 (3.8 %), and 1 grade 4 (0.8 %) surgical complications occurred. Positive surgical margin (PSM) rate was 2.8 %. ERASE in cT1a tumors was associated with a significantly lower need for pedicle clamping, shorter WIT, and lower estimated blood loss (EBL) along with similar operative time and intra and postoperative complication rates but with a significantly lower incidence of urinary fistulas requiring stent insertion compared to laparoscopic SE. Also mean time to drainage removal and length of hospital stay (LOS) were significantly lower in for ERASE. The two groups had comparable PSM rate. ERASE has proven to be a feasible technique for the minimal invasive treatment of clinical stage T1 renal masses. The robotic approach can achieve surgical results superior to those of pure laparoscopy by reducing the need for clamping, WIT, EBL, and LOS.

New approaches to robotic thyroidectomy help to prevent neck scarring and improve surgical ergonomics. The purpose of this study was to compare the efficacy and advantages of a gasless unilateral axillary (GUA) approach and an axillo-breast (GUAB) approach in robotic thyroidectomy. We retrospectively reviewed the data of 131 patients who underwent robotic thyroidectomy with or without central neck dissection using a GUAB (90 cases) or GUA (41 cases) approach between September 2009 and December 2011. We excluded patients who underwent simultaneous lateral neck dissection and cases within the learning curve. We compared patient and tumor characteristics, surgical outcomes, perioperative complications, and cosmetic satisfaction between the two approaches. Robotic thyroidectomy was successful in all patients. There were no differences in terms of patient and tumor characteristics, extent of thyroidectomy and central neck dissection, operative time, and postoperative complications between the two approaches. Cosmetic satisfaction was excellent in both groups. There was no difference in satisfaction with the cosmetic result in the neck area, but the GUA patients expressed higher satisfaction with the appearance of the breast. The surgical outcomes of GUA and GUAB approaches are similar in robotic thyroidectomy. Both are safe, effective, and yield cosmetically excellent results when performed by an experienced robotic thyroid surgeon. However, a GUA approach is associated with superior cosmetic satisfaction with the appearance of the breast.

The open approach continues to be widely performed for ventral hernia repair, while the minimally invasive laparoscopic approach has grown adoption over the last decade. Recently, robotic operation was described as a new modality due to the ease for performing intracorporeal closure of the hernia defect. This study is one of the first multi-institutional case series evaluating robotic-assisted laparoscopic ventral hernia repairs, with the goal of describing robotic-assisted surgical techniques for ventral and incisional hernia repair and the outcomes in teaching and community hospital settings. Medical records of consecutive patients (including surgeon’s learning curve cases) who underwent ventral or incisional hernia repair utilizing the da Vinci Surgical System (Intuitive Surgical Inc, Sunnyvale CA) were retrospectively reviewed. Data collected included preoperative history and perioperative outcomes. Data for a total of 368 patients from four institutions involving five surgeons were analyzed. They were predominantly females (60.3 %), and the mean age was 51 years. The majority of the patients were obese or morbidly obese (47.8 and 20.9 %), and 83.2 % of the patients had a history of prior abdominal operation. Conversion rate was 0.8 %, and mean length of stay was 1 day. Total postoperative complications rate up to 30 days was 8.4 %, of which incidence of paralytic ileus was 2.4 %. This large case series of 368 patients demonstrates reproducibility of safety and performance associated with robotic-assisted ventral hernia repairs performed by five surgeons at four institutions. In addition, the results of short term perioperative outcomes for surgeons during their early experience for robotic-assisted cases are in the range of what is reported in the existing published data on laparoscopic and open ventral hernia repairs. Further comparative evidence initiatives are being pursued to determine the benefits of robotic-assisted technique and technology for long-term and patient-reported outcomes.

Minimally invasive techniques are becoming the gold standard approach to surgical treatment of obesity in adults. Robotic surgical systems have the potential to advance the use and development of minimally invasive procedures. To date, there is no study of outcomes following robotic-assisted gastric banding (RAGB) compared with laparoscopic adjustable gastric banding (LAGB) in children and adolescents. This study was undertaken to compare a single surgeon’s results using the da Vinci surgical system for RAGB with those using LAGB in this group of patients. A retrospective data analysis of 25 patients who underwent RAGB compared with 50 patients who underwent LAGB. The 75 patients were 8–21 years of age and included 42 (54.5%) girls. Patients in the two groups had similar baseline characteristics including gender, age, body mass index (BMI), and presence of comorbidities. No significant differences in complication rate, length of stay or percent excess weight loss at 1 year were found between the two groups. Mean operating time was significantly shorter for LAGB (50 min) compared with RAGB (74 min; P

The key to successful rectal cancer resection is to perform complete total mesorectal excision (TME). Laparoscopic TME can be challenging, especially in the narrow confines of the pelvis. Robotic-assisted surgery can overcome these limitations through superior three-dimensional (3-D) visualization and the increased range of movements provided by the endowrist function. To date, all totally robotic resections of the rectum have been described using da Vinci® S or Si systems. Due to the limitations of the standard system, only hybrid procedures have been described so far.To evaluate the feasibility and short-term outcomes of performing totally robotic-assisted laparoscopic colorectal resections using the standard da Vinci® system with a fourth arm extension.The standard system was docked from the patient's left hip. Four 8-mm robotic trocars were inserted. Upon completion of phase 1 (pedicle ligation, colonic mobilization, splenic flexure takedown), the two left-sided arms are repositioned to allow phase 2 (pelvic dissection), enabling the entire procedure except for the distal transection and anastomosis to be performed robotically.Twenty-one robotic procedures were performed from August 2008 to September 2009. The mean age of the patients was 61 years (13 males). The procedures performed included seven anterior resections, seven low anterior resections, five ultralow anterior resections, one abdominoperineal resection, and one resection rectopexy. The majority of the cases were performed in patients with colon or rectal cancer. Operative time ranged from 232 to 444 (mean 316) min. Postoperative morbidity occurred in three patients (14.3%) with no mortalities or conversions. Average hospital stay was 6.4 days. Mean lymph node yield for the cases with cancer was 17.8.The standard da Vinci® system with four arms can be used to perform totally robotic-assisted colorectal procedures for the left colon and rectum with short-term outcomes similar to those of conventional laparoscopic techniques.

Traditional laparoscopic surgery presents some difficulties for morbidly obese patients due to limited motion of instruments related to a thick abdominal wall, intraabdominal fat, and a large hepatic left lobe, with consequent loss of dexterity and greater musculoskeletal discomfort. Robotic technique could potentially overcome these limitations. This study aimed to evaluate robot-assisted laparoscopic Roux-en-Y gastric bypass in morbidly obese patients and to compare the results of robotic assistance with those of traditional laparoscopic technique. Between September 2006 and June 2009, 110 morbidly obese patients underwent laparoscopic Roux-en-Y gastric bypass with robot-assisted hand-sewn gastrojejunal anastomosis using the da Vinci Surgical System. The data for these patients was compared with the data for 423 consecutive patients treated in a standard laparoscopic manner during the same period. The patients had a mean preoperative age of 42.6 years, a mean weight of 127.5 kg, and a mean body mass index (BMI) of 46.7 kg/m2. The total mean operative time was 247.5 min. The robotic setup time was 10.1 min, and the robotic operative time was 54.5 min. The conversion rate was nil. The intraoperative complication rate was 4.5%. The early and late major postoperative complication rates were 3.6 and 6.4% respectively. The cost per patient was 5777.76 €. For the standard laparoscopy, the operative time was significantly shorter (187 min; p

Various endoscopic thyroidectomy procedures have been designed to minimize visible scarring. However, endoscopic thyroidectomies have some limitations in obtaining adequate surgical views and in the precise manipulations of the endoscopic instrument. Recently, robotic technology has been applied to thyroid surgery. The aim of this study was to determine the technical feasibility, intraoperative safety, and efficacy of robotic thyroidectomy. We analyzed 41 patients with thyroid nodules who underwent robot-assisted endoscopic thyroidectomy from October 2008 to August 2009 using a gasless unilateral axillo-breast or axillary approach with a da Vinci S Surgical System robot at Hanyang University Hospital, Seoul, Korea. We also compared the early surgical outcomes of robotic thyroidectomies with those of 167 patients who underwent conventional open thyroidectomies during the same period. In the robotic group, there were more female patients (P = 0.001) and the mean age was younger than that of the open thyroidectomy group (P

Robotic laparoscopic surgery has revolutionized minimally invasive surgery for the treatment of abdominal pathologies. However, current training techniques rely on subjective evaluation. The authors sought to identify objective measures of robotic surgical performance by comparing novices and experts during three training tasks.Five novices (medical students) were trained in three tasks with the da Vinci Surgical System. Five experts trained in advanced laparoscopy also performed the three tasks. Time to task completion (TTC), total distance traveled (D), speed (S), curvature (kappa), and relative phase (Phi) were measured.Before training, TTC, D, and kappa were significantly smaller for experts than for novices (p0.05), whereas S was significantly larger for experts than for novices before training (p0.05). Novices performed significantly better after training, as shown by smaller TTC, D, and kappa, and larger S. Novice performance after training approached expert performance.This study clearly demonstrated the ability of objective kinematic measures to distinguish between novice and expert performance and training effects in the performance of robotic surgical training tasks.

The da Vinci(®) Surgical System (Intuitive Surgical, Sunnyvale, CA, USA) is a computer-assisted (robotic) surgical system designed to enable and enhance minimally invasive surgery. The Food and Drug Administration (FDA) has cleared computer-assisted surgical systems for use by trained physicians in an operating room environment for laparoscopic surgical procedures in general, cardiac, colorectal, gynecologic, head and neck, thoracic and urologic surgical procedures. There are substantial numbers of peer-reviewed papers regarding the da Vinci(®) Surgical System, and a thoughtful assessment of evidence framed by clinical opinion is warranted.The SAGES da Vinci(®) TAVAC sub-committee performed a literature review of the da Vinci(®) Surgical System regarding gastrointestinal surgery. Conclusions by the sub-committee were vetted by the SAGES TAVAC Committee and SAGES Executive Board. Following revisions, the document was evaluated by the TAVAC Committee and Executive Board again for final approval.Several conclusions were drawn based on expert opinion organized by safety, efficacy, and cost for robotic foregut, bariatric, hepatobiliary/pancreatic, colorectal surgery, and single-incision cholecystectomy.Gastrointestinal surgery with the da Vinci(®) Surgical System is safe and comparable, but not superior to standard laparoscopic approaches. Although clinically acceptable, its use may be costly for select gastrointestinal procedures. Current data are limited to the da Vinci(®) Surgical System; further analyses are needed.

Worldwide, the annual number of robotic surgical procedures continues to increase. Robotic surgical skills are unique from those used in either open or laparoscopic surgery. The acquisition of a basic robotic surgical skill set may be best accomplished in the simulation laboratory. We sought to review the current literature pertaining to the use of virtual reality (VR) simulation in the acquisition of robotic surgical skills on the da Vinci Surgical System.A PubMed search was conducted between December 2014 and January 2015 utilizing the following keywords: virtual reality, robotic surgery, da Vinci, da Vinci skills simulator, SimSurgery Educational Platform, Mimic dV-Trainer, and Robotic Surgery Simulator. Articles were included if they were published between 2007 and 2015, utilized VR simulation for the da Vinci Surgical System, and utilized a commercially available VR platform.The initial search criteria returned 227 published articles. After all inclusion and exclusion criteria were applied, a total of 47 peer-reviewed manuscripts were included in the final review.There are many benefits to utilizing VR simulation for robotic skills acquisition. Four commercially available simulators have been demonstrated to be capable of assessing robotic skill. Three of the four simulators demonstrate the ability of a VR training curriculum to improve basic robotic skills, with proficiency-based training being the most effective training style. The skills obtained on a VR training curriculum are comparable with those obtained on dry laboratory simulation. The future of VR simulation includes utilization in assessment for re-credentialing purposes, advanced procedural-based training, and as a warm-up tool prior to surgery.

Robot-assisted minimally invasive surgery (MIS) has shown tremendous advances over the traditional technique. However, current commercialized systems are complicated and huge, which vastly raises system cost and requirements for operation room. Central South University in collaboration with Tianjin University developed one domestically produced Chinese minimally invasive surgical (MIS) robot system “Micro Hand S” in 2013. Recently, our center launched the first clinical trials of the robot, including one case of robotic gastric perforation repair and two cases of robotic appendectomy. In march 2014, one patient with gastric perforation and two patients with acute appendicitis who underwent robotic perforation repair and robotic appendectomy respectively. In these procedures, we firstly use “Micro Hand S” robot system. All of the patients were followed for 3 months, Total robotic operation time, Intra-operative blood loss and pre- and postoperative changes in routine blood test, liver function test, renal function test and major complications were recorded. “Micro Hand S” succeeded in accomplishing operations. No intraoperative complications or technical problems were encountered. At a three-month follow-up, patients were found to be progressing well, without evidence of adverse reactions. The domestic surgical robot system which was verified as safe and effective through these trials. The proposed design method is an effective way to solve some of drawbacks that exist in the former generations of the da Vinci surgical system.

Robotically enhanced telemanipulation for totally endoscopic coronary artery bypass does not provide adequate tactile feedback, traction, or countertraction. The exposition of coronary target sites is difficult, the visual field is limited, and the epicardial stabilization may be troublesome. A fourth robotic arm for endothoracic instrumentation has been added to the da Vinci surgical system to facilitate totally endoscopic operations. The stereoendoscope was upgraded with a wide-angle feature.The procedure was performed in five patients. Four of these patients had left internal thoracic artery (LITA) to left anterior descending artery (LAD) grafting on the beating heart and the fifth had sequential bypass grafting (LITA to diagonal branch and LAD) on an arrested heart. The additional effector arm of the da Vinci surgical system was brought into the operative field beneath the operating table and used as a second right arm. The wide-angle view was activated by either the console or the patient side surgeon.The mean operative, port placement, and anastomotic times for a beating-heart totally endoscopic coronary artery bypass were 195 +/- 58, 25 +/- 10, and 18 +/- 5 min, respectively. All procedures were free of morbidity and mortality, with satisfactory angiographic control. The sequential arterial bypass grafting procedure was fully completed in totally endoscopic technique.The additional instrumentation arm and wide-angle visualization are useful technical improvements of the da Vinci surgical system, solving the problem of traction, countertraction, and facilitated exposition of target sites as well as visualization of the surgical field. They provide potential for wider acceptance of totally endoscopic coronary artery bypass grafting in a larger surgical community.

Several recent reports have affirmed the feasibility of the laparoscopic approach for radical prostatectomy. In this review, we discuss the morbidities associated with this technique and compare outcomes and convalescence with standard open radical prostatectomy. We reviewed all currently published data on laparoscopic radical prostatectomy and our series of 45 robotic-assisted radical prostatectomies and compared them to several landmark series of open retropubic and perineal radical prostatectomies. Although the initial series reported long operating times, these times have been significantly reduced in more recent series. Data on blood loss, convalescence, impotence, and incontinence rates have also been promising. Although follow-up has been short thus far, laparoscopic radical prostatectomy has been shown to be similar to open radical prostatectomy in several areas.

Intragastric surgery is accepted as a minimally invasive procedure for mucosal or submucosal lesions. Robotic surgery promises to extend the capabilities of the minimally invasive surgeon and many surgical specialties are applying this new technology. However, there is no report of robotic intragastric surgery. We describe the use of the da Vinci® Surgical System for intraluminal mucosal resection of the stomach. We developed our porcine intragastric surgery model using the Tuebingen MIS Trainer. We set a tentative lesion on the posterior wall near the esophagocardiac junction (ECJ) of the stomach and performed mucosal resection of the lesion using the da Vinci Surgical System. We also performed closure of the defect after mucosal resection and subsequent closure of the intentional gastric perforation. Using our porcine intragastric surgery model, we successfully performed mucosal resection of the tentative lesion. We also smoothly completed closure of the defect and closure of the perforation without any complications. The mean size of the mucosa was 6 cm and the mean duration of the procedure was only 12 min. The safety and efficacy of robotic intragastric surgery was preliminarily established in this study. However, further studies are needed to prove its practical feasibility in humans using the da Vinci Surgical System to make it an effective operation.

In response to the technology assessment written by SAGES’ Technology and Value Assessment Committee (TAVAC) and published in this journal, Intuitive Surgical welcomes the opportunity to comment on the methodology and conclusions presented in the analysis. The TAVAC authors reviewed the da Vinci Surgical System technology and evaluated clinical and economic evidence within the specialty area of gastrointestinal surgery. As the scientific representatives of Intuitive Surgical Inc., we have three main concerns with the methodology presented by the TAVAC. First, throughout the assessment, laparoscopic surgery is used as the sole comparator for robotic-assisted surgery. However, robotic-assisted surgery provides a minimally invasive surgery (MIS) option to patients who otherwise would have undergone an open procedure. By limiting the comparator to laparoscopic surgery, the analysis does not account for the substantial number of patients still receiving open procedures in general surgery in the USA (over 50 % of colectomies, over 80 % of rectal surgeries and over 70 % of ventral hernia repairs, for example). Additionally, year-over-year modality comparison data illustrate that the adoption of robotic-assisted surgery has resulted in a decrease in the proportion of open surgery procedures, not a decrease in the proportion of laparoscopic surgical techniques. In fact, for some procedures, the proportion of laparoscopic surgical techniques has increased with the adoption of robotic-assisted surgery (Figure 1A, B). Therefore, we contend that the appropriate comparator for robotic-assisted surgery in this assessment is predominantly open surgery, not laparoscopy. Robotic-assisted surgery is an enabling technology that has been shown to increase the number of patients receiving MIS across large patient populations. Determining which patients receive which type of MIS approach is an important issue for the surgical community. Patient populations matter, and defining the appropriate patient population for different surgical techniques should be a focus of future research. Our second concern is with the methodology for selecting studies included by the TAVAC. These types of assessments typically use a rigorous methodology for identifying and reviewing qualified peer-reviewed literature. The selection criteria used by the Committee are not described, and a broader review shows that the authors omit a significant portion of relevant literature. The assessment primarily uses data that are more than 5 years old—while disregarding more current data that are often at a higher quality and evidence level. Based on our own systematic literature search (filtering for English language and \3b LOE), we found 250 additional, relevant publications that are not included in the technology assessment (Fig. 2; See supplementary online material for references and an appendix for the definition of level of evidence). Electronic supplementary material The online version of this article (doi:10.1007/s00464-015-4679-7) contains supplementary material, which is available to authorized users.

Robot-assisted surgery using the da Vinci Surgical System provides three-dimensional images. However, no research has yet been done on the relationship between the system’s operation and spatial cognitive ability. This study focuses on the operator’s spatial cognitive ability which can impact acquisition of the skills required to operate the da Vinci Surgical System. The participants of the study were 20 volunteers who were students at Hiroshima University (9 men and 11 women, average age 21.1 ± 1.6 years). Depending on the mental rotation test’s score the participants were divided into two groups, one with High group (n = 10), and the other with Low group (n = 10). Both groups were tested using Hiroshima University endoscopic surgical assessment device (HUESAD) and the da Vinci Surgical System simulator dV-Trainer. HUESAD; No significant difference was noted between the two groups in terms of smoothness (p = 0.3867). In terms of accuracy and spatial cognitive ability, the High group scored significantly lower values than the Low group. dV-Trainer; In terms of overall Score, no significant difference was seen between the two groups (pick and place: p = 0.1639; peg board: p = 0.1883; thread the rings: p = 0.8928; suture sponge: p = 0.3238). This study indicates that differences in spatial cognitive ability have no impact at the initial stages to operate the da Vinci Surgical System. Despite this, it should be repeated that the da Vinci Surgical System is not something that facilitates simple surgery that can be implemented by anyone.

Background: Although telerobotic technology has entered clinical application, its value for gastrointestinal surgery is unclear. Our objective was to evaluate the performance characteristics of telerobotically assisted laparoscopic cholecystectomy (TALC). Methods: All TALCs performed using the da Vinci Surgical System between January 2000 and September 2001 at a tertiary academic medical center were analyzed. Results: For this study, 20 patients (80% female) with a mean age of 47 ± 4 years underwent TALC. All had symptomatic cholelithiasis, and all had successful TALC results without complications or need for conversion to conventional laparoscopic cholecystectomy (CLP). The mean procedure time was 152 ± 8 min. The procedures were performed by one of three staff surgeons experienced in laparoscopic surgery who had training in telerobotic surgery. The perceived advantages of TALC over CLP included easier tissue dissection, enhanced dexterity, and stimulated interest in biliary surgery. The disadvantages included increased operating time and lack of tactile feedback. Conclusions: The TALC procedure is effective and safe when performed by appropriately trained surgeons. Telerobotic technology has the potential to reinvigorate gastrointestinal surgery.

Our goal was to analyze reported instances of the da Vinci robotic surgical system instrument failures using the FDA's MAUDE (Manufacturer and User Facility Device Experience) database. From these data we identified some root causes of failures as well as trends that may assist surgeons and users of the robotic technology.We conducted a survey of the MAUDE database and tallied robotic instrument failures that occurred between January 2009 and December 2010. We categorized failures into five main groups (cautery, shaft, wrist or tool tip, cable, and control housing) based on technical differences in instrument design and function.A total of 565 instrument failures were documented through 528 reports. The majority of failures (285) were of the instrument's wrist or tool tip. Cautery problems comprised 174 failures, 76 were shaft failures, 29 were cable failures, and 7 were control housing failures. Of the reports, 10 had no discernible failure mode and 49 exhibited multiple failures.The data show that a number of robotic instrument failures occurred in a short period of time. In reality, many instrument failures may go unreported, thus a true failure rate cannot be determined from these data. However, education of hospital administrators, operating room staff, surgeons, and patients should be incorporated into discussions regarding the introduction and utilization of robotic technology. We recommend institutions incorporate standard failure reporting policies so that the community of robotic surgery companies and surgeons can improve on existing technologies for optimal patient safety and outcomes.

Renal artery aneurysms (RAA) treatment includes both surgical repair and endovascular techniques, mostly depending on the location of aneurysm [1]. For complex RAA located at renal artery bifurcation or distally, open surgical repair represents the gold standard of treatment [2]. However, the transperitoneal open access to the renal artery requires a wide laparotomy—hence the attempt to be minimally invasive with the first reports of laparoscopic approach [3, 4]. Even if it represents a possibility, laparoscopy has not yet gained widespread acceptance for the technical difficulties in performing vascular anastomosis. We herein describe the repair of a complex RAA using the Da Vinci Surgical System. A 41-year-old woman had an accidentally discovered saccular aneurysm of the right renal artery with a maximum diameter of 20 mm, with one in and four out. A laparoscopic robot-assisted approach was planned. Intraoperatively, we confirm the strategy to group the four output branches in two different patches. Thus, a Y-shaped autologous saphenous graft was prepared and introduced through a trocar. For the three anastomoses, a polytetrafluoroethylene running suture was preferred. The total operation time was 350 min, and the estimated surgical blood loss was about 200 ml. Warm ischemia time was 58 min for the posterior branch and 24 min for the second declamping. The patient resumed a regular diet on postoperative day 2, and the hospital stay lasted 4 days. No intraoperative or postoperative morbidity was noted. A CT scan performed 2 months later revealed the patency of all the reconstructed branches. The experience of our group counts five other renal aneurysm repair performed with a robot-assisted technique [5]. The presence of five different arterial branches involved in the reconstruction makes this procedure difficult. Robot-assisted laparoscopic technique represents a valid alternative to open surgery in complex cases.

The U-clip anastomotic device was developed to facilitate interrupted anastomoses without the need to tie sutures. Recently, this technology has been expanded into various fields of surgery. However, in the field of airway reconstruction, there have been no previous reports of this technology being used. The present study examined the technical feasibility of performing safe and efficient robot-assisted endoscopic airway reconstruction using nitinol U-clips in rabbits. A total of six tracheal anastomoses with S60 U-clips were performed using the da Vinci Surgical System. Anastomosis time and complications were recorded. The effectiveness of anastomoses was evaluated by postoperative observation of rabbits for 8 weeks and measurement of anastomotic strictures and pathological findings. All procedures were completed safely. Mean procedure time was 14 ± 1.8 min (mean ± SD). There were no perioperative complications; however, all animals died between postoperative days 14–27, and anastomotic stricture was the likely cause of death. All anastomoses had severe strictures; the mean stricture rate was measured as being 51.1 ± 33.3 (%). Although the technical feasibility of robot-assisted endoscopic airway reconstruction using U-clips has been demonstrated in rabbits, the safety of this technique has not been evaluated. Our data suggest that U-clips are not a feasible approach for airway reconstruction surgery because of the occurrence of severe postoperative anastomotic stricture.

We read the article by Kang et al. [1] entitled RobotAssisted Endoscopic Surgery for Thyroid Cancer: Experience With the First 100 Patients with a great interest. These authors emphasized that robot-assisted endoscopic thyroid operations using a gasless transaxillary approach is a feasible, safe, and effective method for selected patients with thyroid cancer [1]. However, this robotic approach has several disadvantages. The surgeon must be experienced before performing the robotic operation. This new technique needs a da Vinci Surgical System, and its set of instruments requires excessive time. Moreover, the procedure may not be suitable for removing large thyroid tumors. Management complications due to this new technique may be require additional neck incisions and thus a longer operation time due to the narrow surgical area with transaxillary approach. Consequently, robotic thyroidectomy with a transaxillary approach is not a simple method. It can be performed by experienced surgeons in selected surgical clinics.

Robotic gastrectomy in the setting of gastric cancer is reported by some investigators. However, no study has compared robotic surgery with open or laparoscopic surgery for patients with gastric cancer. This study aimed to determine the clinical benefits of robotic gastrectomy over open and laparoscopic gastrectomy for the treatment of gastric cancer. After the introduction of the da Vinci surgical system in November 2007 at the authors’ hospital, 18 robotic gastrectomies were performed from 31 December 2007 to 30 June 2008. The prospective data from gastric cancer patients who underwent gastrectomies (16 robotic, 11 laparoscopic, and 12 open) during the same period were retrospectively analyzed. Sex, age, comorbidity, extent of lymphadenectomy, pT stage, lymph node metastasis, and number of lymph nodes retrieved were similar among the three groups. The estimated blood loss was significantly less in the robotic gastrectomy group than in the open group (p = 0.0312), and the postoperative hospital stay in the robotic group was significantly shorter than in the open and laparoscopic gastrectomy groups (p

Laparoscopic colorectal resection has become popular. The recently developed da Vinci Surgical System promises to facilitate endoscopic surgery and overcome its disadvantages. This study therefore aimed to compare the short-term results between robotic tumor-specific mesorectal excision (R-TSME) using the da Vinci Surgical System and conventional laparoscopic tumor-specific mesorectal excision (L-TSME) in rectal cancer patients. Between April 2006 and February 2007, 36 patients were randomly assigned to receive R-TSME or L-TSME. During the study, 18 patients underwent robotic low anterior resection using the da Vinci Surgical System, and 18 patients had conventional laparoscopic low anterior resection. Patient characteristics, perioperative clinical results, complications, and pathologic details were compared between the two groups. The patient characteristics were not significantly different between the two groups. The mean operating time, hemoglobin change, and conversion rate were not significantly different between the groups. Complications were treated conservatively and did not require surgical intervention in the R-TSME group. The average length of stay was 6.9 ± 1.3 days in the R-TSME group and 8.7 ± 1.3 days in the L-TSME group (p

A robotic virtual-reality (VR) simulator has been developed to improve robot-assisted training for laparoscopic surgery and to enhance surgical performance in laparoscopic skills. The simulated VR training environment provides an effective approach to evaluate and improve surgical performance. This study presents our findings of the VR training environment for robotic laparoscopy. Eight volunteers performed two inanimate tasks in both the VR and the actual training environment. The tasks were bimanual carrying (BC) and needle passing (NP). For the BC task, the volunteers simultaneously transferred two plastic pieces in opposite directions five times consecutively. The same volunteers passed a surgical needle through six pairs of holes in the NP task. Both tasks require significant bimanual coordination that mimics actual laparoscopic skills. Data analysis included time to task completion, speed and distance traveled of the instrument tip, as well as range of motion of the subject’s wrist and elbow of the right arm. Electromyography of the right wrist flexor and extensor were also analyzed. Paired t-tests and Pearson’s r were used to explore the differences and correlations between the two environments. There were no significant differences between the actual and the simulated VR environment with respect to the BC task, while there were significant differences in almost all dependent parameters for the NP task. Moderate to high correlations for most dependent parameters were revealed for both tasks. Our data shows that the VR environment adequately simulated the BC task. The significant differences found for the NP task may be attributed to an oversimplification in the VR environment. However, they do point to the need for improvements in the complexity of our VR simulation. Further research work is needed to develop effective and reliable VR environments for robotic laparoscopic training.

金沢大学大学院医学系研究科

The Federal Drug Administration (FDA) approved the da Vinci surgical system for all abdominal operations in July 2000. In the past 6 years, virtually all gastrointestinal operations have been accomplished using telerobotic techniques. The purpose of this review is to summarize the short-term outcomes achieved with telerobotic gastrointestinal operations.All case series of telerobotic gastrointestinal operations identified by PubMed searches are included in this review.Case series document the safety and efficacy of telerobotic cholecystectomy, fundoplication, Heller myotomy, gastric bypass, colectomy, gastrectomy, and pancreatectomy. The procedures were accomplished with low rates of conversion to laparoscopic operations, mortality, and morbidity. When comparison groups were available, the analysis shows that telerobotic operations required more time than the laparoscopic operations, although for telerobotic cholecystectomy and telerobotic fundoplication, this difference disappeared in 10 to 20 operations. Specific patient advantages were not identified for telerobotic operations compared with laparoscopic operations, except for a decreased esophageal perforation rate during telerobotic Heller myotomy. Surgeons benefited from the three-dimensional imaging, the handlike motions of the robotic instruments, and an ergonomically comfortable position.All telerobotic gastrointestinal operations are feasible and can be performed with safety and efficacy. It is difficult to demonstrate patient-specific advantages of telerobotic surgery over laparoscopic operations. Nonetheless, telerobotic surgical systems offer distinct advantages to surgeons and may facilitate an increase in the number of surgeons performing advanced laparoscopic gastrointestinal operations. In addition, telerobotics offer a digital information platform that enables surgical simulation and augmented-reality surgery.

BACKGROUND: In the last few years, robotics has been applied in clinical practice for a variety of laparoscopic procedures. This study reports our preliminary experience using robotics in the field of general surgery to evaluate the advantages and limitations of robot-assisted laparoscopy. METHODS: Thirty-two consecutive patients were scheduled to undergo robot-assisted laparoscopic surgery in our units from March 2002 to July 2003. The indications were cholecystectomy, 20 patients; right adrenalectomy, two points; bilateral varicocelectomy, two points; Heller's cardiomyotomy, two points; Nissen's fundoplication, two points; total splenectomy, one point; right colectomy, one point; left colectomy, 1 point; and bilateral inguinal hernia repair, one point. In all cases, we used the da Vinci surgical system, with the surgeon at the robotic work station and an assistant by the operating table. RESULTS: Twenty-nine of 32 procedures (90.6%) were completed robotically, whereas three were converted to laparoscopic surgery. Conversion to laparoscopy was due in two patients to minor bleeding that could not be managed robotically and to robot malfunction in the third patient. There were no deaths. Median hospital stay was 2.2 days (range, 2-8). CONCLUSIONS: The main advantages of robot-assisted laparoscopic surgery are the availability of three-dimensional vision and easier instrument manipulation than can be obtain with standard laparoscopy. The learning curve to master the robot was >or= 10 robotic procedures. The main limitations are the large diameter of the instruments (8 mm) and the limited number of robotic arms (maximum, three). We consider these technical shortcomings to be the cause for our conversions, because it is difficult to manage bleeding episodes with only two operating instruments. The benefit to the patient must be evaluated carefully and proven before this technology can become widely accepted in general surgery.

Background: Our objective was to compare the performance of laparoscopic tasks by surgeons using standard laparoscopic instruments and two surgical robotic systems. Methods: Eighteen surgeons performed tasks in a training box using three different instrument systems: standard laparoscopic instruments, the Zeus Robotic Surgical System, and the da Vinci Surgical System. Basic tasks included running a 100-cm rope, placing beads onto pins, and dropping cotton peanuts into cylinders; fine tasks included intracorporeal knot tying and running stitches with 4–0, 6–0, and 7–0 sutures. Time (in seconds) required and precision (number of errors) in performing each task were recorded. Analysis of variance with pair-wise comparisons using the Bonferroni method and Friedman's nonparametric test were used for statistical analysis. Results: Standard instruments performed significantly faster than either robotic system on the rope and bead tasks (p

A decade after the approval of the Da Vinci Surgical System (DVSS) by the US Food and Drug Administration (FDA), evidence of its superiority with respect to safety and efficacy for selected types of surgery compared with conventional laparoscopic surgery (CLS) has been accumulated. The potential advantages of the DVSS over CLS include its greater precision, lower error rates, reduced bleeding, shorter hospital stays, more rapid patient recovery, and reduced pain. As a result many surgeons have begun to use the DVSS in daily practice for a wide variety of surgeries, including general, oncological, urological, gynecological, and cardiothoracic [1]. However, because robotic surgery is still in its early stages, comparativeeffectiveness research (CER) evidence is scarce, and costs must be considered in an economical crisis [2], a more critical approach is required [2]. Robotic surgery may not be suitable for specific types of surgical procedures. A paradigm of potential limitations of robotic surgery was published by Scozzari et al. [3] in the February issue of Surgical Endoscopy. Given the difficulties with traditional laparoscopic surgery for morbidly obese patients, the authors thought to use the DVSS to improve the outcomes of these patients. Data from 110 morbidly obese patients who underwent laparoscopic Roux-en-Y gastric bypass with robot-assisted hand-sewn gastrojejunal anastomosis using the DVSS (DVSS group) were compared with data of 423 patients who underwent standardized CLS group. The patients had a mean weight of 127.5 kg and a mean body mass index (BMI) of 46.7 kg/ m. There were statistically significant differences in favor of the CLS over the DVSS group with respect to the operative time (P \ 0.001) and the cost per patient (P \ 0.001), whereas no differences were found in terms of the intraor postoperative complication rates, revision surgery, or hospital length of stay. The authors concluded that although robot-assisted surgery was safe and intuitive, it did not seem to provide a real advantage over standard laparoscopy in terms of hospital length of stay and complications rates. This study suggests that the use of the DVSS may be indicated for some specific organs and anatomical areas, while it may not be superior to CLS for other disorders and locations. Minimally invasive surgery such as laparoscopyor robot-assisted surgery also has important implications in surgical oncology for a variety of solid tumors. For example, laparoscopic surgery has been the standard approach for colon cancer and promising data have been available for its use in other gastrointestinal cancers, whereas evidence is increasing for the superiority of robotassisted surgery for rectal cancer [4–10]. The age of robotic surgery has dawned and there is still a lot of improvement to be made in the near future. For example, robotic surgery for prostate cancer or rectal cancer is new and has its own learning curve to be overcome. If we remind ourselves of all the debates brought by each new innovative technology, such as laparoscopic surgery, on its first appearance, we believe that further intensive and largescaled studies will answer the upcoming questions about the safety and efficacy of robotic surgery. Translating innovative ideas and concepts into medical practice suggests a key driver to improve health care. However, costs should be considered. A prime paradigm of how costs can drastically be reduced is the competition between biotechnology and pharmaceutical companies and academia regarding next-generation sequencing technology. C. Hottenrott (&) Chirurgische Klinik, St. Elisabethenkrankenhaus, Ginnheimer Strase 3, 60487 Frankfurt am Main, Germany e-mail: info@gastricbreastcancer.com

To the Editor: We thank Dr. Hanisch and Dr. Ziogas [1] for their interest in our article regarding robotic surgery [2] and for their comments. The minimally invasive approach to surgery for gastric cancer has been debated since its first clinical application. At the same time, advanced technique brought the usage of medical robots to the surgical field, which induced another round of debates. The same issues debated for laparoscopic surgery have been debated for robotic gastrectomy including the problems of technical feasibility, long-term outcomes, and cost effectiveness. Among the numerous subjects to be discussed, we focused on rapid adaptation to robots by surgeons familiar with laparoscopic gastrectomy. Robotic surgery is not a new type of surgery but rather a form of advanced laparoscopic surgery because robotic surgery is laparoscopic surgery using instruments with seven degrees of freedom (Endo-wrist instrument, Intuitive Surgical, Sunnyvale, California, USA) but no tremors under a three-dimensional imaging system. Therefore, we focused our report on the da Vinci surgical system, the most advanced laparoscopic tool to date. Efficient operation of this robotic system can be demanding initially. However, the larger experience with robotic gastrectomies shows that initial robotic gastrectomies can be performed by experienced laparoscopic surgeons with satisfactory postoperative outcomes [3]. As exhibited by the results, the postoperative outcomes of initial robotic surgeries were comparable with those of laparoscopic surgeries performed after the learning curve period. The surgeon in the study had performed 177 laparoscopic gastrectomies before starting the robotic gastrectomy [2], which is many more than the 50 laparoscopic gastrectomies at least suggested to overcome the learning curve effect [4, 5]. Thus, we assumed that experienced laparoscopic surgeons could perform robotic gastrectomies with ‘‘a certain level of skill’’ even in an initial series. Although several recent reports have provided evidence that laparoscopic gastrectomy is safe for advanced cancers [6, 7], generally accepted indications for laparoscopic gastrectomy still are limited mostly to early gastric cancer. It is difficult to overcome the learning curve effect of laparoscopic gastrectomy in the West because early gastric cancer there is rare, as Hanisch and Ziogas [1] have described. However, many suggestions for reducing the learning curve effect for advanced laparoscopic procedures have been offered, such as formal training courses, cadaveric resection, close intraoperative supervision by experts, the assistance of experienced surgeons, and careful patient selection during the initial learning period, if possible [8]. With these strategies, surgeons in the West may reduce the learning curve period, although patients and surgeons may not be fully assured. A major concern regarding the application of robotic gastrectomy is whether its high cost will produce a greater benefit. Although several studies regarding this question have been published, no concrete conclusion has been reached [9–11]. Due to the high cost of robotic surgery, conducting a prospective randomized trial is almost impossible. Therefore, well-designed retrospective analyses need to be performed after the accumulation of experience. J. Song Department of Surgery, Kyungpook National University Hospital, Daegu, Korea e-mail: jyewon@gmail.com

To understand the process of skill acquisition in robotic surgery and to allow useful real-time feedback to surgeons and trainees in future generations of robotic surgical systems, robotic surgical skills should be determined with objective variables. The aim of this study was to assess skill acquisition through a training protocol, and to identify variables for the quantification of proficiency. Seven novice users of the da Vinci Surgical System engaged in 4 weeks of training that involved practicing three bimanual tasks with the system. Seven variables were determined for assessing speed of performance, bimanual coordination, and muscular activation. These values were compared before and after training. Significant improvements were observed through training in five variables. Bimanual coordination showed differences between the surgical tasks used, whereas muscular activation patterns showed better muscle use through training. The subjects also performed the surgical tasks considerably faster within the first two to three training sessions. The study objectively demonstrated that the novice users could learn to perform surgical tasks faster and with more consistency, better bimanual dexterity, and better muscular activity utilization. The variables examined showed great promise as objective indicators of proficiency and skill acquisition in robotic surgery.