Da Vinci Surgical System 達文西手臂微創手術
Minimally Invasive Robotic Pancreatic Surgery
Surgical Overview
Led by Professor Yi-Ming Shyr and Professor Shin-E Wang, Director of the Minimally Invasive Surgery Center, the pancreas team at Taipei Veterans General Hospital has been dedicated to advancing robotic pancreaticoduodenectomy (RPD). Pancreatic surgery—particularly the pancreaticoduodenectomy, also known as the Whipple procedure—is widely recognized in the medical field as one of the most complex and challenging operations. Traditional open pancreaticoduodenectomy (OPD) typically results in large incisions and significant postoperative pain. Therefore, minimally invasive surgery has become a global trend, offering smaller wounds and less postoperative discomfort. However, applying minimally invasive techniques to this intricate and lengthy operation requires a highly experienced and professional pancreatic team.
Our team has published more than 70 academic articles on pancreatic diseases and surgeries, including one textbook chapter and 15 papers focused on robotic pancreatic resection. Due to her outstanding contributions, Professor Shin-E Wang was invited as a speaker at the 13th World Congress of the International Hepato-Pancreato-Biliary Association (IHPBA) on September 6, 2018, and was the only representative from Taiwan to participate in drafting the International Guidelines for Minimally Invasive Pancreatic Resection (IG-MIPR), held in Miami, USA, on March 18, 2019.
Surgical Features
The team has successfully implemented the da Vinci Robotic Surgical System for the Whipple procedure. To date, we have completed over 1,800 Whipple surgeries and more than 540 robotic RPD cases, achieving the following outstanding results:
Early Discharge: Patients undergoing RPD were discharged as early as postoperative day 6—nearly a month earlier than those undergoing traditional OPD.
Minimal Scarring: RPD requires incisions as small as 3–4 cm, compared to the 30–40 cm incisions from traditional OPD, about 1/10 in size.
Minimal Blood Loss: In two cases, RPD resulted in zero blood loss, with an average of only 100 c.c., far lower than the typical 500 c.c. from OPD.
Shorter Surgery Time: The shortest RPD operation time was 232 minutes (under 4 hours), significantly shorter than the 6–8 hours required by OPD.
Feasibility in the Elderly: We successfully performed RPD on a 95-year-old patient, proving its safety and applicability even in elderly individuals.
Low Surgical Mortality: The surgical mortality rate is less than 1%.
Over 99% of patients who have undergone minimally invasive RPD expressed satisfaction with the results and would recommend this approach to others with periampullary lesions. Taipei Veterans General Hospital ranks first in Taiwan and remains a leading institution in Asia and worldwide for robotic minimally invasive pancreaticoduodenectomy using the da Vinci system.
Robotic-Assisted Laparoscopic Sacrocolpopexy
Surgical Overview
Pelvic organ prolapse is a common health issue in women, affecting up to 50% of those who have given birth. It refers to the descent of pelvic organs—such as the bladder, uterus, vagina, and/or rectum—from their normal positions in the pelvis. In some cases, the organs may protrude through the vaginal opening, causing symptoms like a sensation of pressure or bulging, difficulty with urination or bowel movements, sexual dysfunction, and a significant decline in quality of life.
Surgical Features
Sacrocolpopexy is an important pelvic reconstructive procedure used to treat enterocele and vaginal vault prolapse. It can also provide apical support during hysterectomy. The surgery can be performed via open abdominal surgery, laparoscopy, or with robotic assistance. The main principle of the procedure is to suspend the vaginal apex to the anterior longitudinal ligament located at the sacral promontory.
Surgical Procedure
The procedure begins by opening the peritoneum over the first sacral joint to expose the anterior longitudinal ligament and the middle sacral vessels. The peritoneum over the anterior vaginal wall is then opened to access the rectovaginal and vesicovaginal spaces. After mobilizing the bladder and rectum, the appropriate mesh length is determined. A Y-shaped mesh is secured to the sacrum using 2 to 3 sutures, and the mesh is anchored to the full thickness of both the anterior and posterior vaginal walls using permanent sutures. Finally, the peritoneum is closed over the mesh to cover the bridge between the vaginal apex and sacrum, reducing the risk of adhesions and bowel obstruction.
Risks and Complications
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Injury to the bladder, ureters, or intestines
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Recurrence of prolapse
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Urinary tract infection
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Hemorrhage
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Ileus (bowel obstruction)
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Dyspareunia (pain during intercourse)
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Mesh exposure or erosion
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Urinary incontinence
This procedure combines the effectiveness of traditional surgery with the advantages of minimally invasive techniques, offering significant benefits in reducing postoperative pain and shortening hospital stay and recovery time.
Laparoscopy-Assisted Colorectal Cancer Resection
The benefits of laparoscopy-assisted surgery are well established and include reduced postoperative pain, less pulmonary suppression, fewer wound complications, faster resolution of ileus, reduced adhesion formation, shorter hospital stays, and quicker recovery compared to traditional open surgery.
Patient Selection and Indications
Despite growing expertise, not all patients with colorectal cancer are ideal candidates for minimally invasive surgery. One limiting factor is a history of prior abdominal surgery. Although previous laparotomy is not an absolute contraindication, the ability to safely access the abdominal cavity and perform adhesiolysis must be evaluated on a case-by-case basis. Other potential risk factors cited in the literature include obesity, advanced age, high ASA score, advanced tumor stage, and emergency presentation. Tumors staged as T4 or located in the transverse colon are commonly excluded in randomized trials. However, these factors are considered relative contraindications depending on the surgeon's experience.
Surgical Procedures
Patients are placed in the lithotomy position under general anesthesia, secured to tolerate deep Trendelenburg positioning. Typically, 4 to 5 trocars are inserted regardless of tumor location. CO₂ pneumoperitoneum is maintained at 12–15 mmHg. A median approach is routinely used.
Right Hemicolectomy:
The assistant elevates the mesentery just caudal to the ileocolic vessels. The peritoneum is incised and extended toward the anterior surface of the duodenum, exposing the superior mesenteric vein. The ileocolic artery and vein are divided, and lymphadenectomy is extended cranially to the root of the middle colic artery. The hepatic flexure is mobilized, and care is taken to preserve the duodenum and Gerota's fascia when dissecting the retroperitoneum. The Toldt's fascia is incised as far cranially and caudally as possible. The ileocecal region is then flipped medially while preserving the right ureter and gonadal vessels. The colon is resected and reconstructed either intra- or extracorporeally through a small umbilical incision using hand-sewn or stapled end-to-end or side-to-side ileocolic anastomosis.
Sigmoidectomy:
The medial aspect of the rectosigmoid mesocolon is incised to access the retroperitoneal space, preserving both hypogastric nerves. The inferior mesenteric artery and vein are divided at their origin. The left ureter and gonadal vessels are identified and preserved. Lateral peritoneal reflection is incised and carried to the median layer. Specimen removal and reconstruction are performed extracorporeally. If the distal colon is too short for extracorporeal anastomosis, an intracorporeal colorectal anastomosis using a circular stapler with the double-stapling technique is performed.
Low Anterior Resection:
After division of the main artery, the pelvis is approached. The rectosigmoid colon is retracted cranially, and dissection is performed laterally for optimal pelvic exposure. The peritoneal reflection is incised anteriorly, Denonvilliers' fascia is divided to expose the seminal vesicles in men or vaginal wall in women. The rectum is mobilized to the level of the levator ani. The mesorectum is incised circumferentially, and a 5 cm midline incision is created for insertion of a linear stapler. The rectal stump is irrigated to prevent anastomotic recurrence. The anastomosis is completed using the double-stapling technique with a circular stapler.
Transanal Total Mesorectal Excision (taTME):
After disinfection and adequate anal dilation, a Lone Star Retractor™ is used to expose the anal canal. Depending on tumor location, intersphincteric resection (ISR) may be performed initially. Mucosal circumferential marking is done 1–2 cm below the tumor margin. A 2–0 purse-string suture is placed on the muscular layer and tied to close the rectal lumen. The mesorectum is dissected through the "Holy Plane" of TME until it meets the abdominal dissection plane.
Laparoscopic exploration, dissection of the inferior mesenteric or superior rectal artery root, and mesenteric membrane resection are performed similarly to conventional laparoscopic-assisted TME. Splenic flexure mobilization is performed if needed to allow tension-free anastomosis.
Note:
The specific risks and complications of laparoscopy-assisted colorectal cancer resection are similar to those of open surgery. Long-term oncological outcomes are also comparable to those of open procedures.
Robotic Staging Surgery for Endometrial Cancer
Endometrial cancer is the most common gynecologic cancer in developing countries, typically occurring in postmenopausal women. It is commonly diagnosed through transvaginal ultrasound and endometrial biopsy. The standard treatment involves surgery, followed by chemotherapy and/or radiation therapy depending on the case. Robotic-assisted surgery is an effective approach for treating endometrial cancer, offering advantages such as lower surgical complication rates and shorter hospital stays compared to traditional laparoscopy or open surgery.
Features:
The purpose of staging surgery in endometrial cancer is both for treatment and accurate staging. By using indocyanine green (ICG) and real-time fluorescent imaging technology (Firefly®) for sentinel lymph node biopsy and dissection, robotic-assisted surgery provides a more sensitive and precise evaluation of lymph node involvement. Key advantages include reduced blood loss, lower risk of lymphedema and complications, and quicker postoperative recovery.
Procedure:
Pelvic lymphadenectomy is performed before the hysterectomy, and para-aortic lymph node sampling is done afterward. The procedure begins with the injection of fluorescent dye into the cervix. The retroperitoneal space is then opened, and anatomical structures are identified via endoscopic visualization. Lymph nodes are dissected, including distal common iliac nodes, nodes around the external iliac vessels, and obturator nodes. Para-aortic lymph nodes are sampled afterward. The fluorescence dye helps accurately identify lymph nodes, which are collected into a specimen bag. A hysterectomy and bilateral salpingo-oophorectomy are then performed, and the specimen is removed via the vagina. The vaginal cuff and surgical wound are sutured closed.
Risks and Complications:
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Intraoperative complications: injury to vessels, bladder, ureters, or intestines
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Leg pain or edema
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Vaginal cuff bleeding, infection, or leakage
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Postoperative infections such as wound infection, urinary tract infection, pelvic abscess, or peritonitis
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Chylous ascites
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Hematoma
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Severe muscle strain
Robot-Assisted Laparoscopic Ureteral Stricture Repair
Robot-assisted laparoscopic surgery offers several advantages, including minimal invasiveness, reduced blood loss, precise suturing and manipulation for optimal repair results, smaller and more aesthetic wounds, shorter recovery time, and reduced hospital stay.
Overview
Ureteral stricture may result from various causes such as congenital ureteropelvic junction (UPJ) obstruction, iatrogenic injury, inflammation, urolithiasis, or prior endoscopic, pelvic, or retroperitoneal surgeries. Common symptoms include flank pain, recurrent urinary tract infections (UTIs), and hematuria. If left untreated, the condition can lead to hydronephrosis, impaired renal function, and kidney atrophy.
Key Features
We use the Da Vinci robotic-assisted laparoscopic system to reconstruct the narrowed segment of the ureter, relieving obstruction and hydronephrosis.
The goals of treatment include:
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Relieving ureteral obstruction and hydronephrosis to preserve kidney function
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Alleviating symptoms such as flank pain, hematuria, and recurrent UTIs
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Avoiding long-term placement of a double J stent, which may cause discomfort, hematuria, and infection
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Reducing the need for frequent double J stent replacements
Surgical Procedure
Under general anesthesia, the narrowed segment of the ureter is surgically removed. Based on the condition, one of the following reconstructive techniques is performed:
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End-to-end anastomosis of the proximal and distal ureteral ends
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Ureteral reimplantation into the bladder
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Ureteral reconstruction and reimplantation using a Boari flap or Psoas hitch technique
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End-to-side anastomosis between ureters
Notes and Risks
This procedure carries a relatively low risk of complications, which may include:
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Risks related to general anesthesia
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Infection
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Hemorrhage
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Urinary leakage
Robotic-Assisted Nephron-Sparing Surgery
For patients diagnosed with small kidney tumors, robotic-assisted partial nephrectomy (RaPN) is a safe and minimally invasive surgical option that allows for effective tumor removal while preserving healthy kidney tissue.
Features
Robotic-assisted partial nephrectomy (RaPN) is a safe and feasible alternative to traditional open or laparoscopic partial nephrectomy for the treatment of early-stage renal cell carcinoma. Compared to open surgery, RaPN offers improved cosmetic outcomes, less postoperative pain, reduced blood loss, and shorter hospital stays. Compared to laparoscopic surgery, RaPN provides the advantages of shorter hospitalization, less intraoperative bleeding, and reduced warm ischemia time.
Procedure Steps
The main steps of the current surgical technique include:
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Patient positioning and trocar placement
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Bowel mobilization and dissection of the renal hilum
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Tumor localization and demarcation
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Clamping of the renal vessels and tumor excision
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Renorrhaphy (repair of the kidney)
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Unclamping of the renal vessels
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Tumor specimen retrieval
Minimally Invasive Total Hip Arthroplasty
The advantages of minimally invasive total hip arthroplasty include a smaller wound size with better cosmesis, less damage of hip muscle (abductors, gluteus medius and minimus) to facilitate early recovery without the need of walking aids.
Overview
Advanced stage of hip diseases including osteoarthritis, traumatic osteoarthritis, osteonecrosis of the femoral head, rheumatoid arthritis, ankylosing spondylitis associated arthritis and hemophilic arthritis of the hip can lead to severe functional impairment and limping because of pain and limited range of motion. Total hip arthroplasty surgery can bring to a smooth articulating surface (resurfacing) as well as to lengthen the affected leg and minimize leg length discrepancy.
Procedures and Features
Minimally invasive surgery
Mean operation time of minimally invasive total hip arthroplasty would be around 50 minutes only or less. Average wound size would be less than 8 to 10 centimeters. More importantly, we do less damage to abductor muscles during the surgery, compared with traditional surgical approaches, thus minimize the incidence of limping after surgery. Walking aids are usually required for only 2 weeks or less after surgery.
Multimodal pain control management
Combined oral, intra-venous or patient-controlled analgesia devices greatly facilitate early rehabilitation and patient satisfaction. Almost all patients can walk well on post-operative day 1 with our pain management.
Venous thromboembolism prevention protocol
VTE (venous thromboembolism) is one of the common complications following total knee arthroplasty, but can be well prevented. Combination of intravenous low molecular weight heparin, low dose aspirin, factor Xa inhibitor in our protocol can effectively protect against this complication.
Professional rehabilitation program
Our team, composed of experienced orthopedic doctors, rehabilitation doctors, physical therapists, special nurses can help patients with their post-operative rehabilitation protocol, including proper body positioning, walking independently with or without walking aids, walking up- or downstairs and to deal with common questions after surgery.
Minimally Invasive Total Knee Arthroplasty
The advantages of minimally invasive total knee arthroplasty include a smaller wound size with better cosmesis, less damage of thigh muscle (quadriceps, vastus medialis) to facilitate early recovery without the need of walking aids.
Overview
Advanced stage of arthritis including osteoarthritis, rheumatoid arthritis, gouty arthritis, traumatic osteoarthritis and spontaneous osteonecrosis of the knee can lead to severe functional impairment because of pain, joint effusion, deformity and limited range of motion. Total knee arthroplasty surgery can bring to a new, smooth articulating surface(resurfacing) as well as to straighten the affected leg (realignment), which is one of the most satisfying surgery in the field of Orthopedics.
Procedures and Features
Minimally invasive surgery
Mean operation time of minimally invasive total knee arthroplasty would be around 30 minutes only or less; simultaneous bilateral total knee arthroplasty would take around 70 minutes or less. Wound size would be approximately 8 to 10 centimeters. More importantly, we do less damage to quadriceps muscle during the surgery, compared with traditional surgical approaches. Therefore, walking aids after surgery are usually not required.
Multimodal patient blood management
We have standard protocol including intra-articular medication to reduce blood loss as well as post-operative blood transfusion, which makes patients safe and comfortable even undergoing simultaneous bilateral total knee arthroplasty.
Multimodal pain control management
Combined oral, intra-venous or patient-controlled analgesia devices greatly facilitate early rehabilitation and patient satisfaction. Almost all patients can walk well on post-operative day 1 with our pain management.
Venous thromboembolism prevention protocol
VTE (venous thromboembolism) is one of the common complications following total knee arthroplasty, but can be well prevented. Combination of intravenous low molecular weight heparin, low dose aspirin, factor Xa inhibitor in our protocol can effectively protect against this complication.
Professional rehabilitation program
Our team, composed of experienced orthopedic doctors, rehabilitation doctors, physical therapists, special nurses can help patients with their post-operative rehabilitation protocol, including continuous passive range of motion exercises with machines, ice-packing, walking independently with or without walking aids, walking up- or downstairs and to deal with common questions after surgery.