Robotic Image Reversal Algorithm:

Image reversal in Natural Orifice Endoscopic Surgery (NOTES) is underestimated in procedures attempted with laparoscopic instruments that only afford four degrees of freedom. Robotic NOTES that applies a third-party endoscope with the robotic instruments of the DaVinci System that have seven degrees of freedom highlights problems of mirrored views in each spatial dimension. Clinical algorithms to orient the operative surgeon with the endoscopist during complex traditional or robotic NOTES procedures are required.

Description:

The video image from a flexible endoscope was spliced through an image reverser into the visual field of the operative console of the DaVinci Robot. The alterations in perceived motion in both the vertical and horizontal axes when looking directly at the trocars as well as in flexed view were recorded first in a lab model and then using two 50 kg pigs where a Robotic NOTES plication with transgastric instrumentation was attempted at the esophageal hiatus.

Results:

Two approaches allow correspondence of both horizontal and vertical movements at the esophageal hiatus- 0o gastroscope rotation with retroflexion approached below the transgastric trocars and the use of the video reverser, and 180o gastroscope rotation with anteflexion approached above the working trocars. Although the latter technique does not require an image reverser for flexed image correspondence, it is much more technically difficult for the endoscopist.

Conclusion:

NOTES instrumentation that requires both direct and flexed visualization through an endoscope is greatly facilitated with the use of a video reverser. Although clinical orientation is facilitated by noting patterns of vertical and horizontal image reversal, automating this mathematical algorithm represents an area of essential technological development.

Minimally invasive techniques limit the mechanical and physiologic stress of their open predecessors. Decreased hospital stay, rapid recovery and decreased perioperative morbidity are positive outcomes that are shared by both laparoscopy and video-assisted thoracoscopic surgery. These minimally invasive approaches spare the patient the debilitating pulmonary effects of a thoracotomy at the cost of increased technical difficulty for an operation already in a precarious anatomic location. Robotic master-slave devices are the newest tools in the surgeons armamentarium. With equivalent port size used in other minimally invasive techniques, these machines promise the operator improved three-dimensional spatial accuracy and increased precision. Esophageal robotics seems ideal when evaluated in a historical context. The minimally invasive approach spares the patient a thoracotomy while precision instrumentation facilitates dissection and anastomosis.