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931 VERROTOUCH: VIBROTACTILE FEEDBACK FOR ROBOTIC MINIMALLY INVASIVE SURGERY
Vol. 185, No. 4S, Supplement, Monday, May 16, 2011
930 CLINICAL PATHWAY FOR DISCHARGE ON POSTOPERATIVE DAY ONE AFTER ROBOTIC PARTIAL NEPHRECTOMY Ketul Shah, Ronney Abaza*, Columbus, OH INTRODUCTION AND OBJECTIVES: A potential benefit of minimally-invasive surgery is reduced hospital stay, but regardless of approach, the complexity of a procedure and potential complications can limit early discharge. Published lengths of stay after robotic partial nephrectomy (RPN) have not been significantly less than those after open surgery. We present a clinical pathway targeting discharge on postoperative day (POD) one after RPN attempting to take advantage of the potentially less morbid procedure with analysis of ability to adhere to the pathway. METHODS: We reviewed all patients undergoing RPN since institution of our clinical pathway. A total of four ports is used with specimen extraction typically at a periumbilical port site and bupivicaine injected at all incisions. Patients ambulate and take clear liquids the night of surgery. Intravenous narcotics are avoided with oral analgesics and ketorolac (renal function permitting) given for pain control. No stent is used and closed suction drains are avoided. The Foley catheter is removed and regular diet started the morning after surgery with discharge the same day. The pathway is used regardless of complexity of the resection. RESULTS: A total of 98 RPNs were performed in 90 consecutive patients with all placed on the pathway. Mean age was 57yrs (22– 83yrs), mean BMI was 32kg/m2 (20 – 49kg/m2), and mean ASA score was 2.8. Mean and median tumor size were 2.9cm and 2.6cm (range, 0.4 –9cm). Mean OR time was 198min and mean blood loss was 187mL with 2 transfusions (2%). Warm ischemia time overall was 11.6min (0 –30.0min) and was 16.1min excluding off-clamp resections. Mean preoperative and discharge serum creatinine were 0.91mg/dL (0.43–2.79) and 1.15mg/dL (0.57–2.93), respectively. All patients ambulated the day of surgery, and none required intravenous narcotics. No stents were placed, and a JP drain was avoided in 82 patients (91%) with only one (1%) experiencing a minor urine leak managed with a Foley catheter for one week. Four ports were adequate in 75 patients (83%). Eighty-five of 90 patients (94%) were discharged on POD#1. Reasons for longer stay included pulmonary concerns, anemia, and negative exploratory laparotomy for suspected bowel injury in one patient each and patient preference in two. Only 4 of 85 patients discharged on POD#1 required readmission within 30 days of surgery (5%), including for fever, anorexia, ileus, and one at an outside facility for pneumonia. CONCLUSIONS: Discharge on POD#1 is feasible in most patients after RPN without increased complications and may represent an advantage over open surgery if such a clinical pathway is applied. Source of Funding: None
931 VERROTOUCH: VIBROTACTILE FEEDBACK FOR ROBOTIC MINIMALLY INVASIVE SURGERY William McMahan, Jamie Gewirtz, Dorsey Standish, Paul Martin, Jacquelyn Kunkel, Magalie Lilavois, Alexei Wedmid, David I. Lee, Katherine J. Kuchenbecker*, Philadelphia, PA INTRODUCTION AND OBJECTIVES: Robotic technology has advanced minimally invasive surgery to mimic human hand motions, but at the cost of diminished haptic and tactile cues. Our VerroTouch system measures the vibrations caused by tool contact and immediately recreates them at the master console for the surgeon to hear and feel. Using VerroTouch on an Intuitive da Vinci S Surgical System, we conducted a human subject study to experimentally evaluate the effect of the audio and haptic feedback on user response and task performance. METHODS: 11 surgeons, with various levels of robotic training, were instructed to execute 3 manipulation tasks (peg transfer, needle pass, and suturing) quickly, accurately, and with minimal force. Each
THE JOURNAL OF UROLOGY姞
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task was performed under 4 different feedback conditions: visual only (V), visual with audio (VA), visual with haptic (VH), and visual with both audio and haptic (VAH). The conditions were presented in pseudorandom order to minimize bias across subjects. Each trial was timed, and both tool accelerations and forces were recorded. Subjects completed surveys after each haptic condition to rate the task and sensory feedback. Results were statistically analyzed using within-subject ANOVA. RESULTS: Survey response showed a mean preference rating across subjects of 0.58 for V, 0.68 for VA, 0.64 for VH, and 0.74 for VAH, with higher rating indicating higher preference. ANOVA showed that audio feedback of tool vibrations had a statistically significant positive effect on preferences, F(1,43)⫽6.25 (p⫽0.018), while haptic feedback was also positive but not quite significant F(1,43)⫽ 2.65 (p⫽0.11). Post-hoc tests showed that the mean ratings for V and VAH are significantly different (p ⫽ 0.02). Comparison between each subject’s most preferred condition and V showed a significant positive preference for some type of tool contact feedback F(1,21)⫽18.37 (p⫽0.002). A significant positive effect was also seen between haptic feedback and the subject’s perceived ability to concentrate. Neither sensory feedback modality was a significant factor in completion time, tool accelerations, nor applied forces. CONCLUSIONS: Surgeons executing manipulation tasks using the da Vinci S robot showed a significant positive preference for feedback of tool contact vibrations through auditory and/or haptic channels, with several expert subjects commenting that it increased their awareness of tool actions. Analysis of the quantitative metrics showed that this additional feedback did not significantly change the speed, accuracy, or force with which subjects completed the chosen tasks. Source of Funding: None
932 ASSESSING PATIENT PREFERENCES AND SATISFACTION OF SINGLE SITE LAPAROSCOPY AND STANDARD LAPAROSCOPY Steven M. Lucas*, Erik A. Pattison, Chandru P. Sundaram, Indianapolis, IN INTRODUCTION AND OBJECTIVES: Laparoendoscopic single-site surgery (LESS) offers the potential for improved cosmesis, recovery, and pain over standard laparoscopy (SL), but little is known about patient preferences when choosing surgery. We present an evaluation of patient-reported preferences for minimally invasive surgery and their satisfaction regarding surgical scars following laparoscopy. METHODS: Patients presenting for follow-up or preoperative consultation were explained the differences between LESS and SL and completed 2 surveys. A preoperative survey asked them to rank factors important in choosing surgery on a 5-point Liekert scale (1: not important, 5: very important). They were successively asked their preference for LESS within the context of recurrence and complications. Postoperatively, patients completed a body-image and scar satisfaction survey. RESULTS: 28 patients (9 females, 18 males, 1 unknown) completed surveys, 5 had not yet had surgery (median age: 58.3, IQR⫽21.0). Preoperatively, the most important factors were surgical success and risk (median⫽5), while number of scars was the least important (median⫽2, IQR⫽2). Pain and return to normal activity were given large importance (median ⫽4). Without any condition, 17% preferred LESS. 42.9% would accept no increase in risk to have LESS, and 89.3% would accept a maximum of 5% increase in risk (median 1% increase). 64.5% would accept no increase in recurrence/failure to have LESS. Females rated scars as more important than males (3, IQR⫽1, v 1, IQR⫽2; p⫽0.013) and tended to prefer LESS slightly more often (3/9 v 2/18, p⫽0.161). Patients ⬍ 50y/o (7) tended to rate scars more important than older patients (median 3, IQR⫽1, vs 2, IQR⫽2; p⫽0.065).
930 CLINICAL PATHWAY FOR DISCHARGE ON POSTOPERATIVE DAY ONE AFTER ROBOTIC PARTIAL NEPHRECTOMY Ketul Shah, Ronney Abaza*, Columbus, OH INTRODUCTION AND OBJECTIVES: A potential benefit of minimally-invasive surgery is reduced hospital stay, but regardless of approach, the complexity of a procedure and potential complications can limit early discharge. Published lengths of stay after robotic partial nephrectomy (RPN) have not been significantly less than those after open surgery. We present a clinical pathway targeting discharge on postoperative day (POD) one after RPN attempting to take advantage of the potentially less morbid procedure with analysis of ability to adhere to the pathway. METHODS: We reviewed all patients undergoing RPN since institution of our clinical pathway. A total of four ports is used with specimen extraction typically at a periumbilical port site and bupivicaine injected at all incisions. Patients ambulate and take clear liquids the night of surgery. Intravenous narcotics are avoided with oral analgesics and ketorolac (renal function permitting) given for pain control. No stent is used and closed suction drains are avoided. The Foley catheter is removed and regular diet started the morning after surgery with discharge the same day. The pathway is used regardless of complexity of the resection. RESULTS: A total of 98 RPNs were performed in 90 consecutive patients with all placed on the pathway. Mean age was 57yrs (22– 83yrs), mean BMI was 32kg/m2 (20 – 49kg/m2), and mean ASA score was 2.8. Mean and median tumor size were 2.9cm and 2.6cm (range, 0.4 –9cm). Mean OR time was 198min and mean blood loss was 187mL with 2 transfusions (2%). Warm ischemia time overall was 11.6min (0 –30.0min) and was 16.1min excluding off-clamp resections. Mean preoperative and discharge serum creatinine were 0.91mg/dL (0.43–2.79) and 1.15mg/dL (0.57–2.93), respectively. All patients ambulated the day of surgery, and none required intravenous narcotics. No stents were placed, and a JP drain was avoided in 82 patients (91%) with only one (1%) experiencing a minor urine leak managed with a Foley catheter for one week. Four ports were adequate in 75 patients (83%). Eighty-five of 90 patients (94%) were discharged on POD#1. Reasons for longer stay included pulmonary concerns, anemia, and negative exploratory laparotomy for suspected bowel injury in one patient each and patient preference in two. Only 4 of 85 patients discharged on POD#1 required readmission within 30 days of surgery (5%), including for fever, anorexia, ileus, and one at an outside facility for pneumonia. CONCLUSIONS: Discharge on POD#1 is feasible in most patients after RPN without increased complications and may represent an advantage over open surgery if such a clinical pathway is applied. Source of Funding: None
931 VERROTOUCH: VIBROTACTILE FEEDBACK FOR ROBOTIC MINIMALLY INVASIVE SURGERY William McMahan, Jamie Gewirtz, Dorsey Standish, Paul Martin, Jacquelyn Kunkel, Magalie Lilavois, Alexei Wedmid, David I. Lee, Katherine J. Kuchenbecker*, Philadelphia, PA INTRODUCTION AND OBJECTIVES: Robotic technology has advanced minimally invasive surgery to mimic human hand motions, but at the cost of diminished haptic and tactile cues. Our VerroTouch system measures the vibrations caused by tool contact and immediately recreates them at the master console for the surgeon to hear and feel. Using VerroTouch on an Intuitive da Vinci S Surgical System, we conducted a human subject study to experimentally evaluate the effect of the audio and haptic feedback on user response and task performance. METHODS: 11 surgeons, with various levels of robotic training, were instructed to execute 3 manipulation tasks (peg transfer, needle pass, and suturing) quickly, accurately, and with minimal force. Each
THE JOURNAL OF UROLOGY姞
e373
task was performed under 4 different feedback conditions: visual only (V), visual with audio (VA), visual with haptic (VH), and visual with both audio and haptic (VAH). The conditions were presented in pseudorandom order to minimize bias across subjects. Each trial was timed, and both tool accelerations and forces were recorded. Subjects completed surveys after each haptic condition to rate the task and sensory feedback. Results were statistically analyzed using within-subject ANOVA. RESULTS: Survey response showed a mean preference rating across subjects of 0.58 for V, 0.68 for VA, 0.64 for VH, and 0.74 for VAH, with higher rating indicating higher preference. ANOVA showed that audio feedback of tool vibrations had a statistically significant positive effect on preferences, F(1,43)⫽6.25 (p⫽0.018), while haptic feedback was also positive but not quite significant F(1,43)⫽ 2.65 (p⫽0.11). Post-hoc tests showed that the mean ratings for V and VAH are significantly different (p ⫽ 0.02). Comparison between each subject’s most preferred condition and V showed a significant positive preference for some type of tool contact feedback F(1,21)⫽18.37 (p⫽0.002). A significant positive effect was also seen between haptic feedback and the subject’s perceived ability to concentrate. Neither sensory feedback modality was a significant factor in completion time, tool accelerations, nor applied forces. CONCLUSIONS: Surgeons executing manipulation tasks using the da Vinci S robot showed a significant positive preference for feedback of tool contact vibrations through auditory and/or haptic channels, with several expert subjects commenting that it increased their awareness of tool actions. Analysis of the quantitative metrics showed that this additional feedback did not significantly change the speed, accuracy, or force with which subjects completed the chosen tasks. Source of Funding: None
932 ASSESSING PATIENT PREFERENCES AND SATISFACTION OF SINGLE SITE LAPAROSCOPY AND STANDARD LAPAROSCOPY Steven M. Lucas*, Erik A. Pattison, Chandru P. Sundaram, Indianapolis, IN INTRODUCTION AND OBJECTIVES: Laparoendoscopic single-site surgery (LESS) offers the potential for improved cosmesis, recovery, and pain over standard laparoscopy (SL), but little is known about patient preferences when choosing surgery. We present an evaluation of patient-reported preferences for minimally invasive surgery and their satisfaction regarding surgical scars following laparoscopy. METHODS: Patients presenting for follow-up or preoperative consultation were explained the differences between LESS and SL and completed 2 surveys. A preoperative survey asked them to rank factors important in choosing surgery on a 5-point Liekert scale (1: not important, 5: very important). They were successively asked their preference for LESS within the context of recurrence and complications. Postoperatively, patients completed a body-image and scar satisfaction survey. RESULTS: 28 patients (9 females, 18 males, 1 unknown) completed surveys, 5 had not yet had surgery (median age: 58.3, IQR⫽21.0). Preoperatively, the most important factors were surgical success and risk (median⫽5), while number of scars was the least important (median⫽2, IQR⫽2). Pain and return to normal activity were given large importance (median ⫽4). Without any condition, 17% preferred LESS. 42.9% would accept no increase in risk to have LESS, and 89.3% would accept a maximum of 5% increase in risk (median 1% increase). 64.5% would accept no increase in recurrence/failure to have LESS. Females rated scars as more important than males (3, IQR⫽1, v 1, IQR⫽2; p⫽0.013) and tended to prefer LESS slightly more often (3/9 v 2/18, p⫽0.161). Patients ⬍ 50y/o (7) tended to rate scars more important than older patients (median 3, IQR⫽1, vs 2, IQR⫽2; p⫽0.065).