{"paper_id":"5ac90a33-541b-42a1-a794-337706c6678a","body_text":"Vol:.(1234567890)\nSurg Endosc (2018) 32:2560–2566\nDOI 10.1007/s00464-017-5957-3\n1 3\nNEW TECHNOLOGY\nFirst experience with THE AUTOLAP™ SYSTEM: an image-\nbased robotic camera steering device\nPaul J. M. Wijsman1 · Ivo A. M. J. Broeders1 · Hylke J. Brenkman2 · Amir Szold3 · \nAntonello Forgione4 · Henk W. R. Schreuder5 · Esther C. J. Consten1 · \nWerner A. Draaisma1 · Paul M. Verheijen1 · Jelle P. Ruurda2 · Yuval Kaufman6 \nReceived: 1 April 2017 / Accepted: 22 October 2017 / Published online: 3 November 2017 \n© Springer Science+Business Media, LLC 2017\nprocedural time, accuracy of imaged-based movements, and \nuser satisfaction.\nResults Surgical procedures were completed with the Auto-\nLap™ system in 64 cases (97%). The mean overall setup \ntime of the AutoLap™ system was 4 min (04:08 ± 0.10). \nProcedure times were not prolonged due to the use of the \nsystem when compared to literature average. The reported \nuser satisfaction was 3.85 and 3.96 on a scale of 1 to 5 in two \nstudies. More than 90% of the image-based movements were \naccurate. No system-related adverse events were recorded \nwhile using the system.\nConclusion Safe and efficient use of the core technology \nof the AutoLap™ system was demonstrated with high image \nstability and good surgeon satisfaction. The results support \nfurther clinical studies that will focus on usability, improved \nergonomics and additional image-based features.\nKeywords Robotic · Steering · Camera holder · \nLaparoscopy · Active camera control systems · Autolap™\nVisualization in endoscopic surgery is a challenge for both \nsurgeon and camera assistant. The surgeon highly depends \non the camera assistant to provide a stable, centered, and \nnon-rotated image of the target area and has no control other \nthan verbal commands or manual correction, which requires \nrelease of one of the instruments.\nAn often encountered pitfall is that the image is unsta-\nble due to tremor, unintended movements or rotation of the \ncamera by the surgical assistant. Furthermore, manual con-\ntrol can also be physically demanding leading to fatigue and \nsuboptimal control. Inexperienced or inattentive assistants \nmay displace the camera frequently, make jerky movements, \nmalposition the laparoscope in relation to the horizon, and \npoint the camera outside the focus of interest more often \nAbstract \nBackground Robotic camera holders for endoscopic sur -\ngery have been available for 20 years but market penetration \nis low. The current camera holders are controlled by voice, \njoystick, eyeball tracking, or head movements, and this \ntype of steering has proven to be successful but excessive \ndisturbance of surgical workflow has blocked widespread \nintroduction. The Autolap™ system (MST, Israel) uses a \nradically different steering concept based on image analysis. \nThis may improve acceptance by smooth, interactive, and \nfast steering. These two studies were conducted to prove safe \nand efficient performance of the core technology.\nMethods A total of 66 various laparoscopic procedures \nwere performed with the AutoLap™ by nine experienced \nsurgeons, in two multi-center studies; 41 cholecystectomies, \n13 fundoplications including hiatal hernia repair, 4 endome-\ntriosis surgeries, 2 inguinal hernia repairs, and 6 (bilateral) \nsalpingo-oophorectomies. The use of the AutoLap™ system \nwas evaluated in terms of safety, image stability, setup and \nand O ther Inte rventional Techniques  \n * Paul J. M. Wijsman \n pjm.wijsman@meandermc.nl\n1 Deparment of Surgery, Meander Medical Center, Maatweg \n3, Amersfoort, The Netherlands\n2 Department of Surgery, University Medical Center Utrecht, \nUtrecht, The Netherlands\n3 Assia Medical Group, Assuta Medical Center, Tel Aviv, \nIsrael\n4 Department of Surgery, Niguarda Cà Granda Hospital, \nMilan, Italy\n5 Department of Gynecologic Oncology, UMC Utrecht Cancer \nCenter, Utrecht, The Netherlands\n6 Department of Surgery, Assuta Medical Center, Haifa, Israel\n\n2561Surg Endosc (2018) 32:2560–2566 \n1 3\nthan experienced assistants [1]. In addition, touching tissues \nwith the camera results in image blurring and a need for fre-\nquent removal of the camera for cleaning. These parameters \ncan cause motion sickness and surgeon distraction that may \nresult in prolonged procedures and patient safety hazards [2].\nRobotic devices have been introduced 20 years ago to \novercome some of these pitfalls [2]. A robotic laparoscopic \npositioner can perform the task of the surgical assistant and \nenables the surgeon to control camera movements person-\nally. Robotic camera holders provide a stable, non-rotated \nfield of view with a focus based on the surgeon’s preference. \nIn the last two decades, different robotic arms have been \ndeveloped, controlled by voice, joysticks, eyeball tracking, \nand head movements. The various commercialized systems \nhave proven to be reliable and efficient but market penetra-\ntion is low. This might be due to excessive hindrance of \nsurgical flow as a result of cumbersome control modalities \ncausing surgeons to decide to rely on human assistants.\nThe AutoLap™ system (MST, Israel) aims to overcome \nunsuccessful camera control concepts by radically changing \nlaparoscope manipulation technology. The steering concept \nis based on image analysis and computer-based instrument \nrecognition instead of direct electromechanical steering \nof a holder that is unaware of the relation between camera \nposition and field of view. The aim of these studies were \nto evaluate reliability and efficiency of the core electrome-\nchanical elements of the Autolap™ system in clinical use. \nThe system was evaluated in terms of safety, image stability, \nprocedural and setup time, accuracy of image-based move-\nments and user satisfaction during general and gynecological \nlaparoscopic surgeries in two multi-center studies, which \nwere conducted in Israel, the Netherlands, and Italy.\nMaterials and methods\nSystem’s description\nThe AutoLap™ (MST, Israel) is an image-guided system \nthat utilizes unique image processing algorithms to enable \nthe motorized movement of the laparoscope at any oblique \npath by following the movement of a designated surgical \ninstrument. It can be mounted on either side of the operating \nbed rail, providing flexibility for supporting various laparo-\nscopic procedures and negates the need for calibration if the \npatient position is altered. The system comprises a robotic \nmotion assembly unit and a processing unit, which holds the \nAutoLap™ unique software and algorithms (Fig.  1). The \nrobotic motion assembly unit, which holds the laparoscope \n(Fig.  2), is covered by a sterile sleeve during the procedure \n(Fig.  3). Control over camera’s movements and operative \nfield is enabled by a small wireless sterile disposable button, \nwhich transmits RF signals and is worn by the surgeon as a \nring or is attached to the surgical tool (Fig.  4).\nThere are three modes of operation, manual operation \nwith a force joystick and two modes initiated by the wireless \nbutton: “joystick mode” and “follow-me mode.” In joystick \nmode, the surgeon can move in four directions; up, down, \nleft, right, and zoom in/out. In follow-me mode, the system \nmovements are controlled by tracking the movements of a \nFig. 1  The main components of \nthe AutoLap™ system\n\n\n2562 Surg Endosc (2018) 32:2560–2566\n1 3\ndesignated tool, which is selected by the surgeon. The sys-\ntem is able to recognize any off-the-shelf surgical tool used \nin laparoscopic surgery and does not need special marking \nor brand.\nAdditionally, the use of the data gathered from the video \nimage enables additional image-based features such as per-\nforming zoom in/out movement with an angled laparoscope \nwhile maintaining the center of the displayed image, correc-\ntion of directional movement in case of camera rotation, pro-\nvide adaptive velocity according to the working zoom level \nand enable digital zoom using the AutoLap™ controller.\nStudy design\nTwo multi-center studies have been performed in five cent-\ners in three countries [Assuta Medical Center Haifa (Israel), \nAssuta Medical Center Tel Aviv (Israel), Meander Medi -\ncal Center (the Netherlands), Niguarda Cà Granda Hospi-\ntal (Italy), UMC Utrecht (the Netherlands)]. The first study \nwas conducted in 2013–2014 to evaluate safety and perfor -\nmance of the AutoLap™ system (the “safety study”, Clini-\ncal Trials.gov identifier NCT01828580). The second study \nwas conducted in 2014–2016 to evaluate the follow-me \nmode (the “follow-me study”, Clinical Trials.gov identifier \nNCT02326870). Patients who were scheduled for hiatal her-\nnia repair/fundoplication, cholecystectomy, endometriosis \nsurgery, (bilateral) salpingo-oophorectomy and inguinal her-\nnia repair were included in both studies. The clinical studies \nwere approved by the centers’s relevant Ethic Committees \nand if required also by the Ministry of Health.\nInclusion criteria were age > 18 and signed informed \nconsent form for both studies. Exclusion criteria for the \nsafety study were previous abdominal surgery and con-\ntraindications to pneumoperitoneum, pregnancy, obesity \n(BMI > 35 kg/m\n2), generalized peritonitis, septic shock \nfrom cholangitis, severe acute pancreatitis, uncorrected \ncoagulopathy, advanced cirrhosis with failure of hepatic \nfunction, suspected gallbladder cancer, acute cholecystitis, \nFig. 2  Laparoscopic- and base unit of the AutoLap™ system\nFig. 3  Setup of the AutoLap™ system during a laparoscopic fun-\ndoplication\nFig. 4  The AutoLap™ Command Unit—ring configuration\n\n2563Surg Endosc (2018) 32:2560–2566 \n1 3\npresence of any medical or psychiatric condition or any \nother condition that, in the opinion of the investigator, \ncould affect the successful participation of the patient in \nthe study and patient participates in any other clinical \nstudy 60 days prior to the start of the study and through-\nout the study duration. Exclusion criteria for the follow-me \nstudy were pregnancy, American Society of Anesthesiolo-\ngist (ASA) classification > 2, and extensive adhesions that \npreclude the standard laparoscopic surgical technique.\nPrimary outcomes of the both studies were adverse \nevents and performance evaluation [operation time (skin \nto skin), number of successful movements]. The procedure \ntime for each type of operation was measured; however, \nno comparison was made with a control group. The aver -\nage percentage of successful movements was calculated by \nthe number of successful movements divided by the total \nnumber of movements during the procedure × 100%. A \nmovement is deemed successful if the laparoscope reached \nthe desired position, which was verbally verified with the \nsurgeon after each movement.\nSecondary outcomes were system setup time (including \ninstallation, draping and positioning), the number of times \nthe laparoscope was removed for cleaning and a usability \nevaluation (questionnaire). Usability questionnaires were \ncompleted postoperatively by the surgeon for subjective \nevaluation of usability aspects, specifically regarding sys-\ntem handling, image stability, effort, satisfaction, and the \nefficiency to perform the procedure with the AutoLap™ \nsystem. Answers were given on a scale ranging from one \n(disagree completely) to five (agree completely, the most \npositive response). Different usability questionnaires were \nused for both studies comprising of 15 questions for the \nsafety study and 18 questions for the follow-me study.\nData analysis\nIn addition to the primary and secondary outcomes, demo-\ngraphic data were recorded including age, gender, ASA \nscore, weight, height, and BMI. The data were analyzed \nwith Excel (Microsoft, Redmond, Washington, 2016).\nResults\nFrom January 2013 to October 2015, 66 patients were \nenrolled to participate in two multi-center studies in five \ncenters. A total of nine surgeons participated in the stud-\nies. The demographic data of the patients are shown in \nTable  1. The number of procedures performed per center \nis shown in Table  2.\nSetup and operation time\nThe mean setup time was 4 min (4:08 ± 0.1). In most cases, \nthe system setup was performed while the patient was being \nprepared for surgery. Draping of the system was mostly done \nduring insufflation of the abdomen, integrating the setup of \nthe system in the normal OR setup time. The mean operative \ntime in minutes for the different procedures are descripted \nin Table  3.\nLaparoscope cleaning\nThe laparoscope was not removed at all in most of the pro-\ncedures. An average of one (0.72 range 0–5) removal per \nprocedure was recorded. In some cases, the need to clean \nthe scope was due to fogging that resulted from tempera-\nture differences and not due to smearing of the lens of the \nlaparoscope.\nNumber of successful movements\nOn average, 99 joystick- and 12.8 follow-me movements \nwere made during a procedure. More than 90% of these \nmovements were successful in both studies. Most of the \nsurgeons used the joystick mode for small movements close \nto the tissue and the follow-me mode for larger movements, \nfurther away from the tissue.\nSafety and usability evaluation\nNo system-induced complications occurred during all the \nperformed procedures. The usability questionnaires dem-\nonstrated adequate satisfaction of all surgeons in all of the \nprocedures with a median score of four (on a scale of 1–5) \nTable 1  Demographic data of the patients\na Recorded only in the safety study\nb Recorded only in the follow-me study\nAll patients (n = 66)\nAge in years (range) 48.9 (23–73)\nGender\n Male 17 (25.75%)\n Female 49 (74.25%)\nBMIa (n = 33) 25.7 (18.7–36.2)\nASAb (n = 32) 1.72 (1–3)\nProcedure type\n Cholecystectomy n = 41\n Hiatal hernia/fundoplication n = 13\n Endometriosis surgery n = 4\n Salpingo-oophorectomy n = 6\n Inguinal hernia repair n = 2\n\n2564 Surg Endosc (2018) 32:2560–2566\n1 3\nin both studies. The average usability score of the safety \nstudy was 3.85 (± 0.37) and 3.96 (± 0.54) for the follow-me \nstudy. The satisfaction specifically related to the usage of the \nfollow-me mode was 3.92. All surgeons expressed satisfac-\ntion from the high image stability provided by the system \n(4.41) as well as the advantage of full control over the field \nof view (3.72), intuitive use (3.76), and anticipated short \nlearning curve (3.97). Less satisfaction was expressed from \nthe release of the laparoscope for cleaning, which had the \nlowest average usability score of 3.1.\nDiscussion\nMinimal invasive surgery has become a leading surgical \nmodality. Every year, the rate of procedures performed is \ngrowing. However, laparoscopy requires a high demand \nof skill, concentration, and maneuverability leading to \nincreased fatigue and physical discomfort for primary sur -\ngeons and assistants [3 ]. Operating in the small pelvis and \nthe upper abdomen is especially physically challenging and \nburdensome. These complex surgeries require the assistant \nto hold the camera for a long period of time at the same, fre-\nquently angled, position. The resulting uncomfortable static \nworking postures can lead to increased strain to different \nparts of the musculoskeletal system [ 4–6]. By improving \nergonomics, primary surgeons and assistants may greatly \nbenefit, allowing them to perform more complex and lengthy \nprocedures with ease.\nDifferent robotic active camera holders have been intro-\nduced in order to improve ergonomics and overcome some \ndisadvantages of laparoscopy. One of the first systems on the \nmarket was the AESOP™ system (Intuitive Surgical, Inc.), \nwhich was controlled by voice or manually. The LapMan™ \n(Medsys S.A, Belgium) uses a joystick that is connected \nto the surgical tool to steer and the EndoAssist™ (Arm-\nstrong Healthcare LLC, UK), which is the first version of \nFreeHand™, uses a combination of a headset with motion \nsensor and a foot pedal to control the laparoscope’s move-\nments. Smaller systems include the ViKY™ system (Endo-\ncontrol, France), FreeHand™ system (OR Productivity plc, \nUK) and the Soloassist™ (Actormed, Barbing, Germany). \nThe Soloassist™ controls the scope with a joystick and the \nViKY™ system with voice control in combination with a \nfoot pedal to ensure that movement is only possible when \nthe pedal is pressed.\nMarket penetration of active robotic camera holders is \nlow. Despite the fact that several types of movement controls \nhave proven to be successful, excessive disturbance of the \nsurgical workflow has blocked widespread introduction. The \nmain difference of the AutoLap™ system with other systems \non the market is the usage of a different steering mechanism \nby image processing software. The AutoLap™ system is not \nlimited to perpendicular movements alone, as can only be \ndone by other systems in the market, but enables the surgeon \nto move the laparoscope in any direction and path. Acquir -\ning the video images and using image processing algorithms \nenables the AutoLap™ to continuously detect the instru-\nments within the field of view and control the laparoscope’s \nmovements according to the instruments’ movements, as \ncommanded by the surgeon.\nIn these studies, the accuracy of the image processing \nalgorithms was 90%. Failure of detecting the tip of the tool \nis caused by several factors. First of all, the image quality \nneeds to be sufficient in order for the algorithm to perform \nproperly. Factors that adversely affect the image quality are \nfogging, blurring, and smearing of the lens. The amount of \nlight in the field of view is also an important factor. A dark \nimage due to poor equipment or a narrow and deep working \nspace like the pelvis can contribute to poorer detection of \nthe tip. Additionally, user errors were made. For instance, \nTable 2  The number of \nprocedures performed per center Number of procedures performed Center\nAmersfoort Utrecht Milan Haifa Tel Aviv\nCholecystectomy 19 9 7 0 6\nHiatal hernia/fundoplication 8 0 0 0 5\nEndometriosis surgery 0 0 0 4 0\nSalpingo-oophorectomy 0 5 0 1 0\nInguinal hernia repair 0 0 2 0 0\nTotal 27 14 9 5 11\nTable 3  Operation time\na Both procedures started with the AutoLap™ system but were not \ncompleted with the system\nTime in minutes\nCholecystectomy (n = 41) 53 (22–87)\nHiatal hernia/fundoplication (n = 13) 69 (50–90)\nEndometriosis surgery (n = 4) 58 (40–80)\nSalpingo-oophorectomy (n = 6) 59 (49–70)\nInguinal hernia  repaira (n = 2) 108 (74–142)\n\n2565Surg Endosc (2018) 32:2560–2566 \n1 3\nactivating the detection algorithm when the tip of the instru-\nment is not within the field of view. Lastly, this was the first \nclinical experience with the image processing algorithms. \nSmall bugs and glitches were detected and corrected during \nthe clinical work, resulting in a new software version.\nThe AutoLap™ system demonstrated to be an effective \nand safe system for robotic camera control during different \ntypes of abdominal procedures in our studies. High image \nstability leading to high surgeons’ satisfaction was reported \nin the questionnaires. No system-induced complications \noccurred and in most procedures the laparoscope did not \nneed to be cleaned due to unintended contact with tissue. \nThe average setup time of the AutoLap™ system is found \nto be comparable with other active camera holders. Wagner \net al. reported an average setup time for the Endoassist™ and \nthe AESOP™ of 2 ± 0.8 and 5.3 ± 2.4 min, respectively [7 ]. \nKommu et al. also measured the setup time for the Endoas-\nsist™, varying from 5.1 ± 1.2 to 6.8 ± 2.3 min depending \non the type of procedure [8]. The average setup time for the \nSoloAssist™ was reported to be 7 min by Beckmeier et al. \n[9] There was a significant learning curve of 20 procedures \nregarding the mounting of the system [9 ]. Maheswari et al. \nreported an average setup time of 3–5 min using the ViKY™ \nsystem in a small study of three patients [10].\nDuring conventional laparoscopy, about 7% of the OR \ntime is spent on cleaning the scope according to a recent \narticle of Yong et al. [11]. Besides the fact that this is a \nconsiderable amount of valuable OR time, cleaning of the \nscope can disrupt the flow of the operation and be very \nfrustrating. In our AutoLap™ trials, the scope was cleaned \nonly once per operation on average. Other trials on robotic \nactive camera holders also demonstrated less frequent clean-\ning of the scope and a reduction or equal total OR time [1 , \n12–14]. However, a longer OR time was demonstrated in a \nstudy by Gillen et al. using the Soloassist™ system, favor -\ning the human assistant [15]. Kommu et al. reported more \nfrequent cleaning of the scope during nephrectomies using \nthe EndoAssist™, which was probably related to the product \ndesign [8].\nAlthough there is no comparison with human assistance \nin our studies, the measured operational times when using \nthe AutoLap™ system are in line with the literature [16–20]. \nComparative studies between human- and robotic camera \nassistance demonstrated similarity in operational procedure \ntimes.[12, 21–23] However, the transabdominal preperito-\nneal hernia procedure (TAPP) took longer compared to lit-\nerature due to hindrance of system, limiting the movement \nrange of the surgeon’s tool. A new curved design of the bar \nsolves this problem, and successful TAPP procedures are \nalready performed with the system.\nThe follow-me mode is based on instrument recogni-\ntion, followed by dragging the camera to the new focus \npoint by a smooth instrument movement. An alternate \nmode of the follow-me, which has been developed fol-\nlowing these studies, is the go-to mode. This mode enables \nthe surgeon to use an instrument to tag the new desired \ncenter field of view. The surgeon moves the tagging tool \nto the new desired center field of view and releases the \nbutton of the remote controller. The field of view will then \nbe centered around the virtually marked new position, at a \ncomparable distance from the tissue. Thus, without losing \ngrip of the surgical instrument, the surgeon only needs to \npoint and click to adjust his desired field of view.\nThe Autolap™ system may prove economic value by \nreducing the number of surgical team members. Several \nprocedures in these studies were performed as solo sur -\ngery, i.e., without the need of a surgical assistant. The \noperation was performed with a surgeon and scrub nurse \nalone. Greater involvement of the scrub nurse may facili-\ntate fewer OR personnel—a factor that may have an impor -\ntant economic impact where skilled staff shortage is an \nobstacle to the performance of laparoscopic surgery.\nThe main limitations regarding the performed studies \nmust be noted. There is a potential risk of bias due to het-\nerogeneity; a total of nine surgeons, in five different cent-\ners, performed six different types of procedures. Moreover, \nthe learning curve was not measured. It is possible that \nsome surgeons were still in their learning process, which \ncan influence the length of the procedures.\nThere are also some limitations regarding the Auto-\nLap™ system. Correct positioning of the system on the \nbedrail is very important to have maximum movement \nrange. Sometimes, adjustments to the positioning have \nto be made by a non-sterile OR personnel during the \nprocedure. Although the system main compartments are \nrather large in appearance, positioning of the system is \nquite flexible. Various types of complex procedures have \nbeen performed successfully with the system outside the \nstudies, including colectomies, surgery in the pelvis and \ngastric surgery. Also, using the wireless disposable button \nwithout losing grip of the instrument takes some practice. \nImprovements of these limitations are being made and will \nbe implemented soon. Examples are a new command unit \ndesign, easy release of the laparoscope and the possibil-\nity to reposition the system by single button activation \nby a sterile person. Future perspectives of the system are \ndevelopment of the next generation system including a \nsmaller footprint and the expansion of the image-based \nproperties, in search for the most effective image-based \nsteering technology without disturbance of surgical flow.\nIn conclusion, the AutoLap™ system is an effective, \nsafe and easy to use system for robotic camera driving dur -\ning a variety of abdominal procedures. Future studies will \nfocus on evaluating additional image-based features, ergo-\nnomic and economic advantages while using the AutoLap™ \nsystem.\n\n2566 Surg Endosc (2018) 32:2560–2566\n1 3\nAcknowledgements The study was sponsored by Medical Surgery \nTechnologies ltd (M.S.T). The company paid the required fees to the \nethics committee and all other relevant study-related expenses. No \nother benefits were received by participating in this study.\nCompliance with ethical standards \nDisclosures Paul Wijsman is a Clinical Field Engineer of Medical \nSurgery Technologies ltd (M.S.T) since 2016. Ivo Broeders, Amir \nSzold, and Yuval Kaufman are the paid members of the Clinical Advi-\nsory Board of M.S.T. Hylke Brenkman, Antonello Forgione, Henk \nSchreuder, Esther Consten, Werner Draaisma, Paul Verheijen, and Jelle \nRuurda have no conflicts of interest or financial ties to disclose.\nReferences\n 1. Dunlap KD, Wanzer L (1998) Is the robotic arm a cost-effective \nsurgical tool? AORN J 68:265–272\n 2. Ballantyne GH (2002) The pitfalls of laparoscopic sur -\ngery: challenges for robotics and telerobotic surgery. \nSurg Laparosc Endosc Percutan Tech 12:1–5. https://doi.\norg/10.1097/00129689-200202000-00001\n 3. Berguer R (1999) Surgery and ergonomics. Arch Surg 134:1011–\n1016. https://doi.org/10.1001/archsurg.134.9.1011\n 4. Hu C-L, Yang C-Y, Lin Z-S, Yang S-Y, Kuo C-H, Lin M-T (2013) \nAn interactive method for achieving ergonomically optimum \nconditions during laparoscopic surgery. J Robot Surg 7:125–130. \nhttps://doi.org/10.1007/s11701-012-0353-4\n 5. Miller K, Benden M, Pickens A, Shipp E, Zheng Q (2012) Ergo-\nnomics principles associated with laparoscopic surgeon Injury/\nIllness. Hum Factors J Hum Factors Ergon Soc 54:1087–1092. \nhttps://doi.org/10.1177/0018720812451046\n 6. Van Der Schatte Olivier RH, Van’t Hullenaar CDP, Ruurda JP, \nBroeders IAMJ (2009) Ergonomics, user comfort, and perfor -\nmance in standard and robot-assisted laparoscopic surgery. Surg \nEndosc Other Interv Tech 23:1365–1371. https://doi.org/10.1007/\ns00464-008-0184-6\n 7. Wagner AA, Varkarakis IM, Link RE, Sullivan W, Su LM \n(2006) Comparison of surgical performance during laparoscopic \nradical prostatectomy of two robotic camera holders, EndoAs-\nsist and AESOP: a pilot study. Urology 68:70–74. https://doi.\norg/10.1016/j.urology.2006.02.003\n 8. Kommu SS, Rimington P, Anderson C, Rané A (2007) Initial \nexperience with the EndoAssist camera-holding robot in laparo-\nscopic urological surgery. J Robot Surg 1:133–137. https://doi.\norg/10.1007/s11701-007-0010-5\n 9. Beckmeier L, Klapdor R, Soergel P, Kundu S, Hillemanns P, \nHertel H (2014) Evaluation of active camera control systems in \ngynecological surgery: construction, handling, comfort, surger -\nies and results. Arch Gynecol Obstet 289:341–348. https://doi.\norg/10.1007/s00404-013-3004-8\n 10. Maheshwari M, Ind T (2015) Concurrent use of a robotic uterine \nmanipulator and a robotic laparoscope holder to achieve assistant-\nless solo laparoscopy: the double ViKY. J Robot Surg 9:211–213. \nhttps://doi.org/10.1007/s11701-015-0518-z\n 11. Yong N, Grange P, Eldred-Evans D (2016) Impact of laparo -\nscopic lens contamination in operating theaters: a study on the \nfrequency and duration of lens contamination and commonly \nutilized techniques to maintain clear vision. Surg Laparosc \nEndosc Percutan Tech 26:286–289. https://doi.org/10.1097/\nSLE.0000000000000289\n 12. Stolzenburg JU, Franz T, Kallidonis P, Minh D, Dietel A, Hicks J, \nNicolaus M, Al-Aown A, Liatsikos E (2011) Comparison of the \nFreeHand?? Robotic camera holder with human assistants dur -\ning endoscopic extraperitoneal radical prostatectomy. BJU Int \n107:970–974. https://doi.org/10.1111/j.1464-410X.2010.09656.x\n 13. Aiono S, Gilbert JM, Soin B, Finlay PA, Gordan A (2002) Con-\ntrolled trial of the introduction of a robotic camera assistant \n(EndoAssist) for laparoscopic cholecystectomy. Surg Endosc \nOther Interv Tech 16:1267–1270. https://doi.org/10.1007/\ns00464-001-9174-7\n 14. Geis WP, Kim HC, Brennan EJ, McAfee PC, Wang Y (1996) \nRobotic arm enhancement to accommodate improved efficiency \nand decreased resource utilization in complex minimally invasive \nsurgical procedures. Stud Health Technol Inform 29:471–481\n 15. Gillen S, Pletzer B, Heiligensetzer A, Wolf P, Kleeff J, Feussner \nH, Fürst A (2014) Solo-surgical laparoscopic cholecystectomy \nwith a joystick-guided camera device: a case-control study. Surg \nEndosc Other Interv Tech 28:164–170. https://doi.org/10.1007/\ns00464-013-3142-x\n 16. Shushan A, Mohamed H, Magos AL (1999) How long does lapa-\nroscopic surgery really take? Lessons learned from 1000 operative \nlaparoscopies. Hum Reprod 14:39–43. https://doi.org/10.1093/\nhumrep/14.1.39\n 17. Minutolo V, Licciardello A, Arena M, Nicosia A, Stefano BDI \n(2014) Laparoscopic cholecystectomy in the treatment of acute \ncholecystitis: comparison of outcomes and costs between early \nand delayed cholecystectomy. Eur Rev Med Pharmacol Sci \n18:40–46\n 18. Morino M, Pellegrino L, Giaccone C, Garrone C, Rebecchi F \n(2006) Randomized clinical trial of robot-assisted versus laparo-\nscopic Nissen fundoplication. Br J Surg 93:553–558. https://doi.\norg/10.1002/bjs.5325\n 19. Keus F, de Jong J, Gooszen HG, Laarhoven CJ (2006) Laparo-\nscopic versus open cholecystectomy for patients with sympto-\nmatic cholecystolithiasis. Cochrane Database Syst Rev. https://\ndoi.org/10.1002/14651858.CD006231\n 20. Memon MA, Subramanya MS, Hossain MB, Yunus RM, Khan \nS, Memon B (2015) Laparoscopic anterior versus posterior fun-\ndoplication for gastro-esophageal reflux disease: a meta-analysis \nand systematic review. World J Surg 39:981–996. https://doi.\norg/10.1007/s00268-014-2889-0\n 21. Proske JM, Dagher I, Franco D (2004) Comparative study of \nhuman and robotic camera control in laparoscopic biliary and \ncolon surgery. J Laparoendosc Adv Surg Tech A 14:345–348. \nhttps://doi.org/10.1089/lap.2004.14.345\n 22. Kalteis M, Pistrich R, Schimetta W, Polz W (2007) Laparoscopic \ncholecystectomy as solo surgery with the aid of a robotic camera \nholder: a case-control study. Surg Laparosc Endosc Percutan Tech \n17:277–282. https://doi.org/10.1097/SLE.0b013e31806030ae\n 23. Kavoussi LR, Moore RG, Adams JB, Partin AW (1995) Urologists \nat work comparison of robotic versus human laparoscopic camera \ncontrol. J Urol 154:2134–2136","source_license":"public-domain-us","license_restricted":false}