REVO

Editor’s Note: Since the introduction of the Korean-developed Revo-i surgical robotic system at Severance Hospital in 2023, it has been actively utilized in various surgical procedures, primarily in urology and general surgery, leading to the completion of 100 successful cases. To commemorate this milestone, this symposium summarizes the background, achievements, and real-world applications of Revo-i not only at Severance Hospital but also in secondary hospitals that have adopted the system.

<Session II. Meet the Revo Surgeons>

1. Experience of Introducing Revo-i at Bundang Jesaeng Hospital (Dr. Jeong-Hwan Son, Head of the Urology Department, Bundang Jesaeng Hospital)

2. The experiences of surgeries using Revo-i surgical system in the community hospital (Dr. Jae Seung Kang, Hongik Hospital)

Chair: Dr. Kang Hyon Song, Director of the Robotic Surgery Center, Korea Cancer Center Hospital

The experiences of surgeries using Revo-i surgical system in the community hospital (Dr. Jae Seung Kang, Hongik Hospital)

Robotic Surgery Cases Using Revo-i in Secondary Hospitals

This presentation focuses on experiences utilizing the Revo-i system in secondary hospitals rather than tertiary medical centers and is structured into three main parts. It first explores the process of gaining robotic surgery experience at a university hospital, followed by a brief introduction to the Revo-i system, and concludes with a detailed explanation of surgical procedures performed with Revo-i, accompanied by real-time surgical videos. The videos were recorded directly from the Revo-i system and are played at normal speed to accurately convey the actual pace of surgery.

I gained my robotic surgery experience as a clinical instructor in the Hepatobiliary and Pancreatic Surgery Department at Seoul National University Hospital (SNUH), where I participated as a First Assistant in approximately 400 da Vinci Xi procedures. Later, as an Assistant Professor at SNUH and a Clinical Assistant Professor at Korea University Guro Hospital, I performed a wide range of surgeries using both the da Vinci Xi and da Vinci SP systems, with a particular focus on hepatopancreato-biliary (HPB) procedures. My expertise includes highly complex robotic surgeries, such as Totally Robotic Pancreaticoduodenectomy (PPPD) and Totally Robotic Extended Cholecystectomy, and based on these clinical experiences, I have served as an Education Committee Member of the Korean Society of Endoscopic & Robotic Surgery, overseeing training programs and acting as the Principal Investigator for educational workshops, while also presenting my research findings at the 2024 Plenary Session of the Society.

Introduction to the Revo-i Surgical Robotic System

The Revo-i surgical robotic system, developed by meerecompany, consists of three primary components: the Vision Cart, the Operation Cart, and the Master Console. The Vision Cart provides high-resolution imaging, ensuring clear visualization during surgery. The Operation Cart houses the robotic arms and surgical instruments, allowing for precise execution of procedures. The Master Console, operated by the surgeon, enables intuitive and precise control of the robotic system. Most procedures are performed using four instruments, allowing for highly detailed and meticulous surgical maneuvers.

Surgical Cases Using the Revo-i System

From January to July 2024, a total of 45 robotic surgeries were performed at the hospital where I worked, with 40 cases conducted by the general surgery department. The most common procedure was cholecystectomy, followed by extended cholecystectomy, transduodenal excision of localized tumors, and a single case of transabdominal preperitoneal (TAPP) inguinal hernia repair, demonstrating the system’s versatility in various surgical applications.

1) Cholecystectomy

Cholecystectomy is the most frequently performed robotic procedure in secondary hospitals, and I would like to share my experience using Revo-i for this surgery. In straightforward cases, a three-port technique was utilized, consisting of one camera port and two working ports. However, in more complex cases such as acute cholecystitis, a four-port approach was employed.

In cases of acute cholecystitis, soft tissue dissection is essential. Rather than using bipolar energy devices or dissectors, I primarily relied on a monopolar hook for dissection. Due to severe inflammation around the cystic duct, more time was required for dissection, and I performed as much of the procedure as possible using the monopolar hook.

When suction was needed during surgery, an additional port was not inserted; instead, pre-positioned gauze was used to manage fluid collection. The cystic duct was cut using the monopolar hook, with no complications observed, and vascular structures were secured with clips to minimize bleeding.

Efficient utilization of all four robotic arms is crucial for optimal surgical outcomes. Acute cholecystitis often presents hemostasis challenges, so the robotic arms were used strategically for tissue retraction and visualization enhancement. The monopolar hook was particularly effective for hemostasis, and if additional bleeding control was required at the end of surgery, gauze was used as a substitute for suction.

2) Extended Cholecystectomy

[Figure 1] Extended Cholecystectomy Method

Extended cholecystectomy is a highly complex procedure rarely performed in secondary hospitals, primarily conducted for patients with gallbladder cancer. This surgery requires dissecting all structures within the hepatoduodenal ligament and performing partial liver resection. Since camera positioning may become restricted during liver resection, ports should be strategically placed slightly higher from the start to better accommodate the surgical site. In the presented case, the patient had a 3 cm tumor and concurrent acute cholecystitis, which posed further challenges during the procedure.

During dissection, a monopolar hook was used, while liver resection was performed using Revo SONIC, an ultrasonic scalpel. Revo SONIC was utilized to ligate larger structures, such as the cystic duct, and a pre-inserted 12 mm port allowed the first assistant to insert necessary instruments into the abdominal cavity in real time. When needed, an additional 12mm assist port was placed to ensure smooth workflow during the operation.

Using Revo SONIC, the hepatoduodenal ligament was meticulously dissected, clearing soft tissues around critical structures like the hepatic artery, portal vein, and common bile duct while preserving them. Simultaneous lymph node dissection ensured a clear surgical field. After confirming major vascular structures, a liver wedge resection was performed with a 1.5 to 2 cm margin around the gallbladder attachment site. The monopolar hook pre-marked the resection area, while rubber bands and sutures created liver tension for controlled excision. During the procedure, Revo SONIC was used in the right hand, with the left operating a retraction instrument for stabilization. Any intraoperative bleeding was effectively controlled with clips and sutures.

For resection of the contralateral liver segment, Revo SONIC was repositioned to the left side, and the same technique of rubber bands and sutures was applied to facilitate accurate tensioning and direction control. Following completion of the wedge resection, hemostasis was achieved using bipolar instruments, and a drain was placed before concluding the surgery.

Previously, this procedure required an open approach, typically performed through a right subcostal incision or an inverted L-shaped incision. However, advancements in minimally invasive surgery have made laparoscopic and robotic-assisted approaches feasible using five ports. Robotic-assisted surgery significantly accelerates patient recovery, leading to a shorter hospital stay, reduced post-operative pain, and higher patient satisfaction. Furthermore, compared to open surgery, patients returned to daily activities much faster, demonstrating the clear benefits of robotic surgery.

3) Transduodenal Excision of a Localized Tumor

Transduodenal excision of a localized tumor is a highly complex procedure that is rarely performed. The surgery involves incising the duodenum to remove the tumor and then suturing the duodenum back together. In this case, the patient was a young woman with a BMI over 30, and a large incision from open surgery was expected to prolong recovery. Additionally, laparoscopic surgery posed challenges due to limited suturing angles, making robotic-assisted surgery the preferred approach, which the patient agreed to.

The most critical step in the early phase of surgery is duodenum mobilization. Since the goal was to remove the tumor while preserving the duodenum in its original state, meticulous precision was required. However, excess abdominal fat further complicates visibility. To overcome this, atraumatic forceps were used to secure the duodenum, while the third robotic arm provided stable traction to improve visibility, allowing for controlled duodenum incision using a monopolar hook.

One of the key advantages of robotic surgery is the stability of its arms, which remain unaffected by external movements. Unlike laparoscopic instruments that may shift due to breathing or other factors, robotic arms provide steady precision throughout the procedure. After incising the duodenum, the tumor was tagged with sutures for easier handling and excised. During suturing, the third robotic arm maintained steady tension, ensuring a stable closure of the duodenal wall and allowing for precise, controlled suturing.

4) Pancreaticoduodenectomy (Whipple’s Operation)

Whipple’s operation is a highly complex procedure involving both resection and anastomosis, with a notably long operative time. While laparoscopic surgery offers advantages in tumor resection due to its rapid instrument exchange and variety of available tools, robotic surgery excels in the anastomosis phase, where stability and precision are critical. Considering these factors, a hybrid approach— utilizing laparoscopy for resection and robotics for anastomosis—offers an optimal balance of efficiency and precision.

[Figure 2] Hybrid Approach in Whipple’s Operation (Laparoscopy + Robotics)

Summary and Conclusion

Revo-i is well-suited for most general laparoscopic procedures. However, the added complexity of robotic surgery, including extra port insertions and docking adjustments, requires careful planning to optimize efficiency. To minimize these challenges, thorough preoperative planning and optimal port placement are essential.

A key advantage of robotic surgery is the third robotic arm’s stability, which enhances precision during procedures. However, surgeons accustomed to laparoscopic procedures may initially find it challenging to integrate this function effectively. Therefore, further research and training on utilizing the robotic arm to its full potential is necessary.

In conclusion, Revo-i is a viable option for both benign diseases and borderline malignant conditions. Sharing experiences among users will be a crucial step in advancing robotic surgery, fostering continuous improvement and development in the field.

Korean Article: https://www.whosaeng.com/158569