however , laparoscopic suturing requires advanced skills , which are mastered during advanced laparoscopic training .
laparoscopic surgery requires many small and precise movements to manipulate and suture tissue in a confined space ; it has shown applicability in pancreatic tumor for staging the disease and at the time of biliary bypass . in 1997 , robotically assisted surgery was proposed for cardiovascular applications .
robotic surgery can increase precision , accuracy , and filter out hand tremor in a micro - anastomosis .
now , sophisticated robot devices can reproduce the surgeon 's movements with the advantage of increased range of motion .
the robot can reproduce a surgeon 's moves rapidly , precisely , and can filter out the tremor of the human hand caused by fatigue .
this study evaluates the feasibility and safety of robotically assisted laparoscopy to perform a roux - en - y hepaticojejunostomy .
pigs received humane care in compliance with the guide for care and use of laboratory animals published by the national institutes of health .
eighteen female yorkshire pigs , weighing 18 kg to 31 kg , underwent a common bile duct ( cbd ) ligation to create a jaundice model . with the pigs under general anesthesia
, 3-ports were placed with mini - laparoscopic instruments ( 2 mm to 3 mm ) .
pneumoperitoneum was performed , a window behind the cbd wall was created , and a distal duct ligation with silk was made .
transabdominal ultrasound was performed 3 to 5 days later , and the cbd diameter was measured and documented for follow - up .
once the cbd distention was confirmed , the animals were randomly assigned to 3 groups for the roux - en - y hepaticojejunostomy ( hj ) : open ( n=6 ) , standard laparoscopy ( lap ) ( n=6 ) , and robotically assisted laparoscopy ( zeus ) ( n=6 ) .
one surgeon , who had clinical experience in the assistant position in laparoscopic hepaticojejunostomy , performed all 3 approaches with the help of 1 assistant .
neither the surgeon nor the assistant had experience with robotics in surgery . in the open group , under general anesthesia , the abdomen was prepped and draped in sterile fashion for ventral midline laparotomy .
once the common bile duct dilation was confirmed , the roux - en - y was performed as a side - to - side enteroenterostomy at 40 cm from the angle of treitz by using a 3.0 running suture .
a 1-cm incision at the common hepatic duct and small bowel was made , and the side - to - side hepaticojejunostomy was performed with a double running 4 - 0 suture . starting with the superior vertex , the posterior wall was initially made with a running suture and later tied with the separate suture from the anterior wall , tying both sutures at the inferior vertex .
closure of the abdominal wall was accomplished in 2 layers . in the standard laparoscopic group ,
pneumoperitoneum with a veress needle was made at the umbilicus and maintained with a 12 mm hg pressure .
the liver was retracted with cephalic gallbladder traction with an endograsp through the right lower port to expose the common bile duct .
port placement in standard laparoscopy group and robotically assisted group ( zeus system , computer motion , inc ) ; surgeon 's instruments ( a , b ) ; endocamera ( aesop ) ( c ) ; assistant ( d , e , f ) .
the roux - en - y was performed by exposing the small bowel through the umbilical port , and side - to - side enteroenterostomy was performed outside the peritoneal cavity . after completion
, it was reintroduced into the peritoneal cavity , pneumoperitoneum was reestablished , and the roux - en - y was retracted cephalic close to the cbd .
the hj was performed in the same fashion as described for the open group , with a double running suture using intracorporeal knots with laparoscopic needle drivers .
voice control of the aesop camera allows the surgeon to simultaneously manipulate the laparoscopic camera and 2 laparoscopic surgical instruments from a remote location . the surgeon operated seated in an armchair in front of a console including a monitor and control instruments .
movements of robotic handles are transmitted to a computer controller that filters the moves , reduces the tremor , and then translates the surgeon 's movements to the robotic arms .
the scale can be managed in a way that a robot reproduces in smaller scale the surgeon 's movements for more precision ( figure 2 ) . the zeus system ( computer motion , inc . )
while voice control of the aesop ( b ) manipulates remotely the laparoscopic camera , movements of robotic handles are transmitted to a computer controller translating the surgeon 's movements to the robotic arms . in the zeus approach ,
all the surgical steps were reproduced as in the standard laparoscopy group until the time of hj when the zeus sterile devices were set up . the surgeon operated from the console while the assistant stood between the robotic arms for tissue traction .
the time required for the hj for the 3 groups , number of stitches on the posterior and anterior wall , and the total time of surgery were analyzed .
the animals were recovered from the anesthesia with proper care after surgery and were sacrificed 2 weeks later for anastomosis inspection . to analyze the data regarding the differences between the groups
, we used 3 types of tests : multiple comparison tests , 2-sample t tests , and paired t tests .
three to 5 days after creation of the jaundice model with mini - laparoscopic cbd ligation , ultrasound was performed prior to the biliary bypass .
the cbd was measured , confirming dilatation with a mean of 17 , 15 , and 16.8 mm for the open , lap , and zeus groups , respectively .
one of the 18 pigs in the lap group developed a small ischemic hole on the anterior wall of the cbd after ligation .
no free collections were shown in the ultrasound ; this was probably an ischemic consequence of the ligation .
this case was diagnosed at the time of surgery , and the cbd wall was sutured ( 4.0 running suture ) adding 20 minutes with a laparoscopic approach before performing the hj .
analyzing roux - en - y time , a statistical difference was found between the open ( 20.2 min ) and the lap and zeus ( 39.2 and 40.5 min ) procedures .
summary of surgical time for open , standard laparoscopy , and robotically assisted laparoscopy groups before the hepaticojejunostomy , the robot set up for sterilized procedures included covering 3 arms with a sterile plastic cover required a mean of 30.16 minutes ( range , 18 to 45 ) with a fast learning curve .
no difference was noted in the total number of stitches used in hj among the 3 groups . when comparing zeus to lap ( 2-sample t test ) , the former required fewer stitches on the posterior wall of the hj ( p=0.0083 ) .
the time needed for the posterior wall of the hj between lap and zeus showed zeus was faster . the total time required for hj and surgery compared with that in lap and zeus were similar ( table 2 ) .
hepaticojejunostomy for the open , standard laparoscopy , and robotically assisted laparoscopy groups postoperative complications related to roux - en - y and hj included 2 small bowel obstructions ( 11.1% ) and 2 instances of ischemia / necrosis in the small bowel ( 11.1% ) in the lap group . only 1 pig ( 5.5% ) developed a bile leak at the anastomosis due to a broken suture ( first case of zeus group ) .
one pig developed a subcapsular hepatic hematoma found at necropsy ( 5.5% ) ( zeus group ) , probably due to instrumentation .
the roux - en - y hepaticojejunostomy by a laparoscopic approach is a technically demanding procedure that requires knowledge of advanced laparoscopic suturing and the intracorporeal knot technique .
significant suture practice is required , especially when smaller instruments are used to master the technique .
trainees usually spend many hours practicing before competency is achieved . a strong limitation while suturing with laparoscopic instruments is the angle of work between the direction of the needle drivers and the direction of the anastomosis line . in standard and robotically assisted laparoscopy , the most time - consuming and critical factor in performing the hepaticojejunostomy was establishing the proper working angle in the anastomosis and the instruments .
robotics appears to provide some advantages to the surgeon , such as improved range of motion and filtering out hand tremor to allow micro suturing .
still , no proven benefits to the patient have been shown with these models in general surgery .
the laparoscopic instruments are fixed to the port and the tip is rigid . the robotic device
used at duke university was an initial prototype with a fixed tip of the instrument similar to that in laparoscopic instruments . today
, new robots have a  micro - wrist  in the instrument tip that allows the surgeon to have a complete flexible tip like a little  hand  inside the abdominal cavity with wrist mobilization through a small access port .
robotics may have an application in laparoscopic suturing , the learning curve is mainly to achieve the suturing task , and minimizing work angle difficulty .
garcia - ruiz et al compared manual with robotically assisted laparoscopic maneuvering for suturing and found that the laparoscopic manual approach was faster when the size of the suture increased .
we did not find differences in the total time of anastomosis ( hj ) in these 2 groups ; we performed all anastomoses with the same suture size .
the posterior wall of the hj took less time for the zeus group than for standard laparoscopy group ( table 2 ) even after excluding one laparoscopic case ( l4 ) which presented with a difficult angle of work ( 2-sample t test , p=0.02049 ) .
when using the zeus at the first robotically assisted anastomosis , this animal developed a postoperative bile leak due to a broken suture at the superior vertex of the anastomosis .
this complication was caused by a loss of tactile perception with the robot instruments and a mesh in the suture , feedback that is important when tying the suture knot .
a surgeon must learn how to handle the suture while maintaining visual control through the monitor .
we found that once the surgeon has some training in laparoscopic intracorporeal suturing , the learning curve for the robotic device is short .
the basic concept of intracorporeal suturing is the same in laparoscopy and robotics because the instruments are similar .
we believe that when the technique is mastered , the laparoscopic or the robotic - assisted approach does not make a difference , especially in this non - microwrist device .
the critical factor of the angle may be minimized with more advanced robotic prototypes , such as flexible tip instruments .
this brings a new concept , hands inside the peritoneal cavity through mini - invasive access , and it may show a difference for intracorporeal suturing techniques .
robotically assisted laparoscopic roux - en - y hepaticojejunostomy is a feasible procedure that requires the same operative time as that of standard laparoscopy .
 introduction : this study evaluates the feasibility and safety of using robotically assisted laparoscopy to perform a roux - en - y hepaticojejunostomy . 
 this new method was compared with the open and standard laparoscopic approaches.methods:eighteen pigs underwent a needlescopic common bile duct ligation to create a jaundice model . 
 three to 5 days later , transabdominal ultrasound was performed , and the common bile duct diameter was documented . for the roux - en - y hepaticojejunostomy , the pigs were randomly assigned to the open group ( n=6 ) , standard laparoscopy group ( n=6 ) , or robotically assisted laparoscopy group ( zeus ) ( n=6 ) . 
 one surgeon performed all 3 approaches with 1 assistant . 
 operative times , techniques , and complication rates were documented.results:the open approach was faster in all instances . at the hepaticojejunostomy 
 , no difference was noted between the groups with the total number of stitches used . 
 the robot required fewer stitches and less time in the posterior wall of the hepaticojejunostomy ( p=0.0083 and p=0.02049 , respectively ) . 
 the hepaticojejunostomy time was similar for the laparoscopy and robotically assisted groups.conclusion:robotically assisted laparoscopic roux - en - y hepaticojejunostomy is a feasible procedure . 
 when compared with standard laparoscopy , operating time is similar . 
INTRODUCTION
METHODS
RESULTS
DISCUSSION
CONCLUSION