Home Informed consent in robotic surgery: quality of information and patient perception
Article Open Access

Informed consent in robotic surgery: quality of information and patient perception

  • Alessia Ferrarese EMAIL logo , Giada Pozzi , Felice Borghi , Luca Pellegrino , Pierpaolo Di Lorenzo , Bruno Amato , Michele Santangelo , Massimo Niola , Valter Martino and Emanuele Capasso
Published/Copyright: August 2, 2016
Download Article (PDF)
Open Medicine
From the journal Open Medicine Volume 11 Issue 1

Abstract

Introduction

Obtaining a valid informed consent in the medical and surgical field is a long debated issue in the literature. In robotic surgery we believe in the necessity to follow three arrangements to make the informed consent more complete.

Material and methods

This study presents correlations and descriptions based on forensic medicine concepts research, literature review, and the proposal of an integration in the classic concept of informed consent.

Conclusion

In robotic surgery we believe in the necessity to follow three arrangements to make the IC more complete. Integrate the information already present in the informed consent with data on the surgeon’s experience in RS, the number of procedures of the department and the regional map of expertises by procedure.

Key words: Informed consent; Surgery; Robotic surgery

Highlights

  1. Obtaining a valid informed consent in the medical and surgical field is a long debated issue in the literature

  2. Considering patients, some factors affect the IC comprehension like: demographic and familiar context, socio-economical aspects, clinical history and listening attitude

  3. The advent of robotic surgery confronted all surgical specialists with the problem of the old consents suitability

  4. In robotic surgery we believe in the necessity to follow three arrangements to make the informated consent more complete with data on the surgeon’s experience in RS, the number of procedures of the department and the regional map of expertises by procedure

1 Introduction

Obtaining a valid informed consent in the medical and surgical field is a long debated issue in the literature. In daily clinical practice surgeons have to ensure to their patients maximum understanding of the upcoming procedures.

Over the years, technology development and the creation of new high-complexity aids, made the correct obtaining of IC more difficult for two reasons: the intrinsic complexity of surgery, and the difficulty in explaining it in a comprehensible form for the patient.

The advent of robotic surgery confronted all surgical specialists with the problem of the old consents suitability. Despite the fact that surgical patients are indirectly protected by clinical trials and strict ethical rules, surgical specialists remain concerned.

Gynaecologists were the first to write about the issue; then the problem was discussed by cardiac surgeons and urologists, and eventually by digestive surgeons. International surgical societies involved in the robotic field suggested an open discussion with the patient about technical innovations of the procedures, but they didn’t define which are the essential aspects to explain so that an IC can be considered valid [1].

This study presents correlations and descriptions based on forensic medicine concepts research, literature review, and the proposal of an integration in the classic concept of IC. The aim is to evaluate the need for introducing a specific IC for complex high-technology surgery, like robotic, to participate in the “informed debate” on the role of informative standards in surgery.

2 The informed consent

The concept of IC boasts a long history. Its origins lie at the ancient Egyptians times, when doctors believed that their medicines had to benefit their patients while not being detrimental. The current concept of IC developed on this basic principle: the fundamental element of doctor-patient relationship is based on the patient’s free choice to undergo the proposed medical procedure. Procedures themselves must follow the international societies standards of care.

Considering patients, some factors affect the IC comprehension like: demographic and familiar context, socio-economical aspects, clinical history and listening attitude [2,3].

According to recent literature data, however, patients show a poor comprehension of ICs, regardless their different characteristics. They try to focus on the diagnosis and on the understanding of the organ that will be affected by the procedure. In addition, not every patient looks for the same degree of detail, so the surgeon should calibrate the information in accordance to the request [4].

More data from literature show that patients require the doctor to be informed about all possible complications (which is by the way impossible) but it is shown that in the end he doesn’t use this information to decide whether or not to undergo the procedure, but just to have a better idea of what to expect [5].

Considering the surgeon, we know that the setting in which the discussion takes place has a major influence, from the moment when IC is obtained, to who the explaining doctor is.

This aspect is covered in Hagihara’s 2006 paper [6], indicating as factors influencing patients information perception: doctor’s age, gender and years of experience, duration of the explanation, exposition clarity and the training level (estimated by patients sensations) of the doctor.

3 Robotic surgery

Minimal invasive robot-assisted surgery enters the history of surgery in the mid 2000s and experienced a rapid growth in the last decade. Data form 2010 estimate that only from 2007 to 2009 the number of Da Vinci robotic Systems sold has nearly doubled, from 800 to more than 1400 only in the United States, and a growth from 200 to 400 outside the US. Numbers are still increasing.

The first surgeons using this system were Gynaecologists and Urologists. As regards digestive surgery, robotic technology application had a substantial growth in the last 5 years, reaching a prominent position for the treatment of benign and malignant gastrointestinal pathologies [7].

As a result of the advent of a real technologic revolution, we are witnessing a remodelling of both surgical and legal aspects.

4 Robotic concepts and legal implications

4.1 Learning curve and definition of expert robotic surgeon

4.1.1 General considerations

The two main issues still characterising robotic surgery, in all disciplines, are the absence of a defined learning curve (LC) and of an agreement on the adequate certification needed to be considered robotic surgeons.

The LC for a given intervention is the number of procedures that a surgeon has to perform to reach an acceptable level of error in line with the literature. Once this number is reached, the surgeon can be considered an expert in that procedure.

Robotic surgery LC takes into account another aspect: the proper use of the machine. Unlike the concept of LC in laparoscopic surgery, that maintains intrinsic the knowledge of laparoscopic instruments, in robotic surgery the

experience of the surgeon must be tested also as regards fluency in devices use, knowledge of instruments, robotic units mobilization and capability in resolving technical problems of the system.

This need emerged when some literature reviews defined the lack of technical competence as one of the major causes of mistakes in high technology based surgery [8].

Food and Drugs Administration defines as a minimal standard to call themselves a robotic surgeon a 1-2 days course with the use of the robotic platform simulator, achieving a diploma [9].

Other authors declare that to obtain this certification, beyond the basic course, the performance of at least 4 surgeries as first operator at the console is required.

Despite these indications, however, each surgical speciality tends to suggest different LCs; the process is also influenced by surgeons previous abilities, therefore it’s not easy to standardise an universally recognised number of procedures [10].

4.1.2 Legal implications

With the IC surgeons should be able to inform patients about the minimum number of procedures a surgeon should perform to avoid errors in an acceptable way. In robotic surgery this is non yet possible. During the IC obtaining the patient should be informed about this concept, even at the expense of a more significant concern of the patient himself. In RS, moreover, the knowledge of the procedure should be integrated with the knowledge of the system.

To ensure the proper development of RT maintaining as ultimate goal patients safety, international surgical societies established three fundamental concepts: the role of the simulator, precepting and proctoring concepts.

4.2 The importance of robotic simulator

Simulators maintain the relevance that it had in laparoscopic surgery, but its usage becomes easier because it comes down to a software applicable to the robotic console. Every operative robot can therefore become a simulator when they are unused. This is essential because it allows a surgeon to make mistakes without any consequence on a patient. Moreover, having the opportunity to use the same system used in the operating room, surgeons acquire the complete knowledge of instruments, perspective and surgical setting.

During the IC acquisition, directly or by information brochures, patients should be informed about pre-opera-tive preparation through simulations.

4.3 Definition and role of preceptor and proctor

4.3.1 General considerations

In an interesting Zorn et al. 2009 paper, the definition and role of the two supervisors in robotic surgery is established: “preceptor” and “proctor”. The first one is the teacher responsible for the operation; preceptors responsibly observe the procedure, give advice and must intervene if the operator gestures are inadequate or the patient is generally at risk.

The second one, the proctor, validates a surgeon competence; he gives to the hospital recommendations about the surgeon’s results based on his observation in the operating room. Basing on these indications the hospital will recommend to the surgeon a preceptor, or will allow privileges or restrictions about procedures a surgeon can or can not perform [11]. According to US authors a distinction between these two figures is essential, because a different role during the operation leads to a different role in the procedures legal responsibilities.

While the proctor, as a pure observer, maintains a position that is free of direct responsibilities, the preceptor is directly involved in all the decision making process during the procedure, being the surgical tutor.

Lastly, the proctor should be associated to every robotic surgeon, expert and non-expert, to test the evolution of their competence, while the preceptor is only associated to non-expert surgeons until they complete their LC.

When problems of a classic IC acquisition add up to those arising from new technologies introduction and new figures involved in the procedure, it creates an instability in information with relevant legal implications.

4.3.2 Legal implications

As we said, the Tutor or Preceptor is directly involved in robotic surgery legal aspects. But a question arises about the real Proctor’s involvement for a complication during surgery: is he really exempted from all responsibility? There is no clear answer to this question but in the literature we find some examples where in lawsuits Proctors had no legal implications.

In the literature is also emphasised Proctors heterogeneity, due to non restrictive requisites to gain this role (20 procedures performed), EBM rules laid down by the machine manufacturers [12].

The definition of Preceptor is easier to understand but is not regulated by any written rule. He is the typical expert surgeon teaching a less expert colleague a procedure.

So despite the first operator is responsible and shall be accountable for his actions, the tutor remains the first responsible for the procedure. The transfer of responsibility is based on the same concept as some legal causes where the surgeon performing an operation for a neoplastic lesion, diagnosed by biopsy but not found in the final post-operative histology, is cleared to the detriment of the pathologist that signed the initial diagnosis [13].

In fact procedures responsibility (like diagnosis responsibility in the pathologists case) is borne by the person that can change the course of the procedure thanks to his experience.

During the IC obtaining for robotic surgery, therefore, the presence of Preceptor and Proctor should be indicated and responsibilities must be made clear for both surgeon and patient.

5 Legal concepts and implications in robotic surgery

5.1 Negligence and causal link

5.1.1 General considerations

For a doctor to be accused of negligence 4 elements of guilt must be proven: non-compliance to duty of care, deviation from standards of care, lesion evidence, causal link between the lesion and the lack of care [14].

So the lesion on the patient has to be proven, along with the doctor’s deviation from standards of care: moreover a link must exist between the damage suffered by the patient and the strategy adopted by his doctor, for the case to exist. These possible damages must be explained to the patient during the IC acquisition; however there is no rule making clear the level of information owed to a patient.

We report some legal measures based on an IC lack of explanations on some possible complications, resolved in favour of the accused doctor and finding answers in the knowledge of the causal link.

For example in the judgment Chappel Vs Hart, it looks like the surgeon didn’t let the patient know a particular complication that happened during surgery [15]. The judgment underlines the difficult concept that the damage to a patient has to be related to negligence and not to lack of information. For a better understanding, the authors suggest asking ourselves some questions like: is the damage occurred because of the lack of information, or did this preclude the patient the possibility of choosing a better treatment, or did it expose the patient to a greater risk? Or even: if, aware of the possibility of that complication, the patient would postpone the surgery, would the risk diminish? The answer could be simple, but in our opinion the security of non-guilt with an incomplete IC is not so granted.

5.1.2 Implications in robotics

The 4 principles for negligence persecution are universal and apply in RS like in classical or laparoscopic surgery.

The standard of care is an universal concept too with no specific varying in RS. However, there is no unanimity about robotic surgery as a Gold Standard for any specific procedure; there are no clear data in the literature.

When obtaining an IC in RS we should make explicit the possible implication of this technique on complications, if the technique increases the risk of improper manoeuvres or if it makes them easier.

5.2 Standard of care and loss of chance

5.2.1 General considerations

The standard of care is the reasonable way to cure, based on EBM (evidence based medicine), on guidelines, and ensures patients the correct management of the disease, keeping the error probability in an acceptable range.

The concept of loss of chance is based on the right of the patient to undergo a procedure relying on the most expert surgeon. The surgeon anyway operates in the standard of care like the other specialists, but a patient must be able to choose which specialist will take care of his problem.

In the case mentioned before [15], for better understanding the fail of these two concepts, the questions would be: knowing the degree of risk of this complication defined in the literature, is the risk increased if the procedure is performed by this surgeon? If the answer is no, the case doesn’t exist. Laws about negligence, in fact, are

necessary to whom who suffered a damage because of a deviation from the standard of care, but they don’t compensate people who received an intervention according to the standard of care even if it could have been better performed by another surgeon.

In other words, laws must compensate people who lost the possibility to be cared for in an optimal way, but not who lost the possibility to be cared for in a better way (in the standard of care limits). This apparently relieves the burden of the IC acquisition, but legal wrangling on this topic is still increasing.

Lobina et al. in 2007 published an interesting paper on the assessment of the real IC understanding by the surgeon [5]. Aim of this work was to test the preparation and the knowledge of surgeons themselves about basic legal concepts related to the IC obtaining. Authors declare in conclusion that, despite the median level of preparation of surgeons was high, the legal aspect of ICs is rarely reached in clinical practice.

Surgeons should educate patients, as well as about the standards of care that are often implicitly expressed, also about the concept of chance, stating the level of experience of the surgical equipe and the possibility of a more suitable specialist in the territory.

5.2.2 Implications in robotics

The concept of loss of chance could possibly turn against traditional surgery in the coming years, if data about less discomfort and better oncological results in RS will be confirmed. Legal dictates state that, during the informative conversation, surgeons should inform about the possibility to perform the same SP with another technique with better results, even if this will redirect the patient towards another colleague.

Second implication in RS is the failure to declare the surgeon’s skills.

Especially in high complexity procedures the need is felt to declare the capacities and the experience of the surgeon, to clarify and make patients choice easier and more correct. This problem could be avoided by preparing a “catalogue” system of all surgeons, following the US scheme, produced by hospitals.

Actually this aspect could create three problems: first, limits on number of procedures to perform to become (and remain) a reference surgeon for a given procedure should be established; second, hospitals should publish their results, and third they should ensure that patients read and interpret these results correctly.

So the complexity of structuring this standard of control is clear, as the difficulty in standardising the concept among all typologies of patients.

In our reality it is currently inapplicable; therefore it becomes even more necessary, especially in complex procedures, discussing these aspects directly with the patient during the obtaining of the IC.

6 Discussion

There are different ways to consider the IC. For many years it was based on the concept of “beneficiality” of medical and surgical procedures, so that a surgeon’s actions were always justified whatever the results, because they were useful for the protection of the patient.

In the years following, with surgical procedures increasing and the evolution of surgeons and devices, concluding contracts of trust between doctor and patient became necessary. By the way, clear rules never existed about what to say exactly during a informative talk, which information provide, which complications talk about, and what information is necessary for an universal validation of the consent itself [16].

Even most legal medicine specialists don’t recognize an universal concept of information-based consent; some of them in fact have been advocating for years that for an ill patient whose last chance of cure is a surgical operation, the procedure itself is not a digression at all, but the natural evolvement of the history of the disease. Therefore it wouldn’t need a consent, but on the other hand the decision not to undergo the procedure should be certified as a “reasoned refusal”.

In 1936 the vice-principal of Harvard faculty of Medicine stated that in an ideal society the only foundation for a consent should be trust, and that “a written consent should make a patient suspicious and result in a request for clarifications to elucidate the reasons behind such a formality”. Well aware that we don’t live in an ideal reality, and motivated by an increasingly rapid technology development and by the increasing number of legal sanctions, surgical societies with legal medicine institutes established some rules to regulate doctor-patient relationships, and expressed the need for a written disclosure that will accompany each invasive procedure on an human being. This should include not only procedure related variables but also all the possible alternatives to that procedure, that surgeon or that timing.

We bring as an example the “Martin Salgo case” discussed in 1957, whose judgment confirms the obligation to give a global information comprising each eventuality, in line with the concept of “smart consent”.

As previously stated, a “lacking consent” is mainly due to a patient’s inability to figure out the information and to a doctor’s poor ability in explaining the proposed procedure [17]. In RS technical complexity increases, and therefore some authors state that patient’s difficulties in understanding increase too; even for the surgeon there can be difficulties in clarifying a complex procedure.

Because of this technological development, many authors began to express a concrete need for a specific IC regulation, and in 2012 Susan J. Lee Char et al suggested a scheme to follow for a correct IC acquisition based on a survey of N° patients [18]. It considered the generic procedure description with technical details, potential risks, experience and outcomes of the surgeon, and in the end how much the procedure was appealing and effective in the eyes of the surgeon himself.

Some authors declare that currently, thanks to more precise rules, to the potential use of devices and to the higher level of education in the average population, we can observe a settling in information perception that is positively influenced by an increased efficacy of surgeons and patients greater will to understand [19]. Other authors claim that patient’s procedures comprehension is not compromised by robotic complexity in itself. More studies however state that any new notion about difficult techniques inevitably leads to an increasing struggle in understanding.

A more complete and standardised IC, and above all the knowledge of the complex process needed for technology application in surgery, are essential factors to deal with the remaining problems and to limit subsequent legal implications.

6.1 Limitations of the study

This is a purely observational study based on the literature, and we didn’t directly compare surgeons and patients populations on these concerns.

We based our work on experiences found in the literature coming from different surgical specialities and about different surgical operations. So it’s not necessarily true that our conclusions could be standardised to all surgical fields.

7 Conclusions

Currently the IC is influenced by many factors that led to an acquisition not just based on the concept of correct care, but also on the avoidance of legal sanctions. Therefore, applying a defensive medicine, the concept of informed consent is shifting towards a more appropriate concept of defensive-informed consent.

In robotic surgery we believe in the necessity to follow three arrangements to make the IC more complete. Integrate the information already present in the IC (causes of the disease, consequences of the disease if not treated, focus on the proposed technique, possible consequences if treated and risk of reintervention with related consequences) with data on the surgeon’s experience in RS, the number of procedures of the department and the regional map of expertises by procedure.

It would be helpful to inform patients about the figures of Proctor, Preceptor and assistant, with their usefulness and their responsibilities in robotic surgery.

Finally, it is incumbent to ask the surgical societies to produce RS guidelines to give to patients, to define LCs of the main procedures and to consider a constant training on simulators using the figures of tutors and proctors.

All of this should happen in order to improve patients educational process in robotic surgery, supporting technology evolution without putting aside the correct interpretation and acquisition of the informed consent.

  1. Conflict of interest statement: Authors state no conflict of interest.

References

[1] Reitsma AM, Moreno JD. Ethics guidelines for innovative surgery: Recommendations for national policy. In: Reitsma AM, Moreno JD, editors. Ethical guidelines for innovative surgery. Hagerstown, University Publishing Group, 2006Search in Google Scholar

[2] Lidz CW. The therapeutic misconception and our models of competency and informed consent. BehavSci Law 2006, 24, 535-54610.1002/bsl.700Search in Google Scholar

[3] Verheggen FW, Jonkers R, Kok G. Patients’ perceptions on informed consent and the quality of information disclosure in clinical trials. Patient Educ Couns 1996, 29,137-15310.1016/0738-3991(96)00859-2Search in Google Scholar

[4] Beresford N, Seymour L, Vincent C, Moat N. Risks of elective cardiac surgery: what do patients want to know? Heart. 2001, 86, 626-63110.1136/heart.86.6.626Search in Google Scholar PubMed PubMed Central

[5] Larobina ME, Merry CJ, Negri JC, Pick AW. Is informed consent in cardiac surgery and percutaneous coronary intervention achievable? Anz J Surg. 2007, 77, 530-53410.1111/j.1445-2197.2007.04143.xSearch in Google Scholar PubMed

[6] Hagihara A, Tarumi K. Doctor and patient perceptions of the level of doctor explanation and quality of patient-doctor communication. ScandJ CaringSci. 2006, 20,143-15010.1111/j.1471-6712.2006.00420.xSearch in Google Scholar PubMed

[7] Barbash GI1, Glied SA. New technology and health care costs: the case of robot-assisted surgery. N EnglJ Med. 2010, 363, 701-70410.1056/NEJMp1006602Search in Google Scholar PubMed

[8] Rogers SO Jr, Gawande AA, Kwaan M et al. Analysis of surgical errors in closed malpractice claims at liability insurers. Surgery 2006,140, 2510.1016/j.surg.2006.01.008Search in Google Scholar PubMed

[9] Visco AG, Advincula AP. Robotic gynecologic surgery. Obstet Gynecol. 112 2008,1369-138210.1097/AOG.0b013e31818f3c17Search in Google Scholar PubMed

[10] Steinberg PL, Merguerian PA, Bihrle W 3rd et al. The cost of learning robotic-assisted prostatectomy. Urology 2008, 72, 106810.1016/j.urology.2007.11.118Search in Google Scholar PubMed

[11] Zorn KC, Gautam G, ShalhavALet al. Training, credentialing, proctoringand medicolegal risks of robotic urological surgery: recommendations of the society of urologic robotic surgeons. J Urol. 2009,182,1126-113210.1016/j.juro.2009.05.042Search in Google Scholar PubMed

[12] Mavroforou A, Michalodimitrakis E, Hatzitheo-Filou C, Giannoukas A. Legal and ethical issues in robotic surgery. Int Angiol. 2010, 29,75-79Search in Google Scholar

[13] Megally v LaPorta, 253 2d 679 2d 649 (NY App 1998)Search in Google Scholar

[14] Granade PF. Medical malpractice issues related to the use of telemedicine: an analysis of the ways in which telecommunications affects the principles of medical malpractice. N Dak Law Rev. 1997, 73, 65Search in Google Scholar

[15] Chappelv. Hart, 195 Commonwealth Law Reports 1998, 232Search in Google Scholar

[16] Mallardi V. The origin of informed consent. Acta Otorhi-nolaryngol Ital. 2005, 25, 312-327Search in Google Scholar

[17] Francs V, Korsch BM, Morris MJ. N EngJ Med 1969, 280, 535-54010.1056/NEJM196903062801004Search in Google Scholar PubMed

[18] Lee Char SJ, Hills NK, Lo B, Kirkwood KS. Informed consent for innovative surgery: a survey of patients and surgeons. Surgery. 2013,153, 473-48010.1016/j.surg.2012.08.068Search in Google Scholar PubMed PubMed Central

[19] Ryan S, Chirumamilla V, Bello RA, D’Alessandro DA et al. How Informed is “Informed Consent” for Robotic Cardiothoracic Surgery? Innovations 2009, 307, 307-31010.1097/imi.0b013e3181c45e4fSearch in Google Scholar

Abbreviations
IC

Informed Consent

RS

Robotic Surgery

LC

Learning Curve

EBM

Evidence Based Medicine

RT

Robotic Technique

Received: 2016-6-11
Accepted: 2016-6-13
Published Online: 2016-8-2
Published in Print: 2016-1-1

© 2016 Alessia Ferrarese et al.

This work is licensed under the Creative Commons Attribution-NonCommercial-NoDerivatives 3.0 License.

Articles in the same Issue

  1. Research Article
  2. The possible molecular regulation mechanism of CIK cells inhibiting the proliferation of Human Lung Adenocarcinoma NCL-H157 Cells
  3. Case Report
  4. Urethral stone of unexpected size: case report and short literature review
  5. Case Report
  6. Complete remission through icotinib treatment in Non-small cell lung cancer epidermal growth factor receptor mutation patient with brain metastasis: A case report
  7. Research Article
  8. FPL tendon thickness, tremor and hand functions in Parkinson’s disease
  9. Research Article
  10. Diagnostic value of circulating tumor cells in cerebrospinal fluid
  11. Research Article
  12. A meta-analysis of neuroprotective effect for traditional Chinese medicine (TCM) in the treatment of glaucoma
  13. Research Article
  14. MiR-218 increases sensitivity to cisplatin in esophageal cancer cells via targeting survivin expression
  15. Research Article
  16. Association of HOTAIR expression with PI3K/Akt pathway activation in adenocarcinoma of esophagogastric junction
  17. Research Article
  18. The role of interleukin genes in the course of depression
  19. Case Report
  20. A rare case of primary pulmonary diffuse large B cell lymphoma with CD5 positive expression
  21. Research Article
  22. DWI and SPARCC scoring assess curative effect of early ankylosing spondylitis
  23. Research Article
  24. The diagnostic value of serum CEA, NSE and MMP-9 for on-small cell lung cancer
  25. Case Report
  26. Dysphonia – the single symptom of rifampicin resistant laryngeal tuberculosis
  27. Review Article
  28. Development of epidermal growth factor receptor tyrosine kinase inhibitors against EGFR T790M. Mutation in non small-cell lung carcinoma
  29. Research Article
  30. Negative regulation of CDC42 expression and cell cycle progression by miR-29a in breast cancer
  31. Research Article
  32. Expression analysis of the TGF-β/SMAD target genes in adenocarcinoma of esophagogastric junction
  33. Research Article
  34. Blood cells in thyroid cancer patients: a possible influence of apoptosis
  35. Research Article
  36. Detected EGFR mutation in cerebrospinal fluid of lung adenocarcinoma patients with meningeal metastasis
  37. Mini-review
  38. Pathogenesis-oriented approaches for the management of corticosteroid-resistant or relapsedprimary immune thrombocytopenia
  39. Research Article
  40. GSTP1 A>G polymorphism and chemosensitivity of osteosarcoma: A meta-analysis
  41. Research Article
  42. A meta-analysis of adiponectin gene rs22411766 T>G polymorphism and ischemic stroke susceptibility
  43. Research Article
  44. The diagnosis and pathological value of combined detection of HE4 and CA125 for patients with ovarian cancer
  45. Research Article
  46. SOX7 inhibits tumor progression of glioblastoma and is regulated by miRNA-24
  47. Research Article
  48. Sevoflurane affects evoked electromyography monitoring in cerebral palsy
  49. Case Report
  50. A case report of hereditary spherocytosis with concomitant chronic myelocytic leukemia
  51. Case Report
  52. A case of giant saphenous vein graft aneurysm followed serially after coronary artery bypass surgery
  53. Research Article
  54. LncRNA TUG1 is upregulated and promotes cell proliferation in osteosarcoma
  55. Review Article
  56. Meningioma recurrence
  57. Case Report
  58. Endobronchial amyloidosis mimicking bronchial asthma: a case report and review of the literature
  59. Case Report
  60. A confusing case report of pulmonary langerhans cell histiocytosis and literature review
  61. Research Article
  62. Effect of hesperetin on chaperone activity in selenite-induced cataract
  63. Research Article
  64. Clinical value of self-assessment risk of osteoporosis in Chinese
  65. Research Article
  66. Correlation analysis of VHL and Jade-1 gene expression in human renal cell carcinoma
  67. Research Article
  68. Is acute appendicitis still misdiagnosed?
  69. Retraction
  70. Retraction of: application of food-specific IgG antibody detection in allergy dermatosis
  71. Review Article
  72. Platelet Rich Plasma: a short overview of certain bioactive components
  73. Research Article
  74. Correlation between CTLA-4 gene rs221775A>G single nucleotide polymorphism and multiple sclerosis susceptibility. A meta-analysis
  75. Review Article
  76. Standards of anesthesiology practice during neuroradiological interventions
  77. Research Article
  78. Expression and clinical significance of LXRα and SREBP-1c in placentas of preeclampsia
  79. Letter to the Editor
  80. ARDS diagnosed by SpO2/FiO2 ratio compared with PaO2/FiO2 ratio: the role as a diagnostic tool for early enrolment into clinical trials
  81. Research Article
  82. Impact of sensory integration training on balance among stroke patients: sensory integration training on balance among stroke patients
  83. Review Article
  84. MicroRNAs as regulatory elements in psoriasis
  85. Review Article
  86. Influenza A(H1N1)pdm09 and postpandemic influenza in Lithuania
  87. Review Article
  88. Garengeot’s hernia: two case reports with CT diagnosis and literature review
  89. Research Article
  90. Concept of experimental preparation for treating dentin hypersensitivity
  91. Research Article
  92. Hydrogen water reduces NSE, IL-6, and TNF-α levels in hypoxic-ischemic encephalopathy
  93. Research Article
  94. Xanthogranuloma of the sellar region diagnosed by frozen section
  95. Case Report
  96. Laparoscopic antegrade cholecystectomy: a standard procedure?
  97. Case Report
  98. Maxillary fibrous dysplasia associated with McCune-Albright syndrome. A case study
  99. Regular Article
  100. Sialoendoscopy, sialography, and ultrasound: a comparison of diagnostic methods
  101. Research Article
  102. Antibody Response to Live Attenuated Vaccines in Adults in Japan
  103. Conference article
  104. Excellence and safety in surgery require excellent and safe tutoring
  105. Conference article
  106. Suggestions on how to make suboptimal kidney transplantation an ethically viable option
  107. Regular Article
  108. Ectopic pregnancy treatment by combination therapy
  109. Conference article
  110. Use of a simplified consent form to facilitate patient understanding of informed consent for laparoscopic cholecystectomy
  111. Regular Article
  112. Cusum analysis for learning curve of videothoracoscopic lobectomy
  113. Regular Article
  114. A meta-analysis of association between glutathione S-transferase M1 gene polymorphism and Parkinson’s disease susceptibility
  115. Conference article
  116. Plastination: ethical and medico-legal considerations
  117. Regular Article
  118. Investigation and control of a suspected nosocomial outbreak of pan-drug resistant Acinetobacter baumannii in an intensive care unit
  119. Regular Article
  120. Multifactorial analysis of fatigue scale among nurses in Poland
  121. Regular Article
  122. Smoking cessation for free: outcomes of a study of three Romanian clinics
  123. Regular Article
  124. Clinical efficacy and safety of tripterygium glycosides in treatment of stage IV diabetic nephropathy: A meta-analysis
  125. Special Issue on Italian Society for the Study of Vascular Anomalies
  126. Prevention and treatment of peritoneal adhesions in patients affected by vascular diseases following surgery: a review of the literature
  127. Special Issue on Italian Society for the Study of Vascular Anomalies
  128. Surgical treatment of recidivist lymphedema
  129. Special Issue on Italian Society for the Study of Vascular Anomalies
  130. CT and MR imaging of the thoracic aorta
  131. Special Issue on Italian Society for the Study of Vascular Anomalies
  132. Role of FDG-PET scan in staging of pulmonary epithelioid hemangioendothelioma
  133. Special Issue on Italian Society for the Study of Vascular Anomalies
  134. Sternal reconstruction by extracellular matrix: a rare case of phaces syndrome
  135. Special Issue on Italian Society for the Study of Vascular Anomalies
  136. Prenatal diagnosis, 3-D virtual rendering and lung sparing surgery by ligasure device in a baby with “CCAM and intralobar pulmonary sequestration”
  137. Special Issue on Italian Society for the Study of Vascular Anomalies
  138. Serum levels of inhibin B in adolescents after varicocelelectomy: A long term follow up
  139. Special Issue on Italian Society for the Study of Vascular Anomalies
  140. Our experience in the treatment of Malignant Fibrous Hystiocytoma of the larynx: clinical diagnosis, therapeutic approach and review of literature
  141. Special Issue on Italian Society for the Study of Vascular Anomalies
  142. Delayed recurrent nerve paralysis following post-traumatic aortic pseudoaneurysm
  143. Special Issue on Italian Society for the Study of Vascular Anomalies
  144. Integrated therapeutic approach to giant solitary fibrous tumor of the pleura: report of a case and review of the literature
  145. Special Issue on Italian Society for the Study of Vascular Anomalies
  146. Celiac axis compression syndrome: laparoscopic approach in a strange case of chronic abdominal pain in 71 years old man
  147. Special Issue on Italian Society for the Study of Vascular Anomalies
  148. A rare case of persistent hypoglossal artery associated with contralateral proximal subclavian stenosis
  149. Focus on Medico-Legal and Ethical Topics in Surgery in Italy
  150. Contralateral risk reducing mastectomy in Non-BRCA-Mutated patients
  151. Focus on Medico-Legal and Ethical Topics in Surgery in Italy
  152. Professional dental and oral surgery liability in Italy: a comparative analysis of the insurance products offered to health workers
  153. Focus on Medico-Legal and Ethical Topics in Surgery in Italy
  154. Informed consent in robotic surgery: quality of information and patient perception
  155. Focus on Medico-Legal and Ethical Topics in Surgery in Italy
  156. Malfunctions of robotic system in surgery: role and responsibility of surgeon in legal point of view
  157. Focus on Medico-Legal and Ethical Topics in Surgery in Italy
  158. Medicolegal implications of surgical errors and complications in neck surgery: A review based on the Italian current legislation
  159. Focus on Medico-Legal and Ethical Topics in Surgery in Italy
  160. Iatrogenic splenic injury: review of the literature and medico-legal issues
  161. Focus on Medico-Legal and Ethical Topics in Surgery in Italy
  162. Donation of the body for scientific purposes in Italy: ethical and medico-legal considerations
  163. Focus on Medico-Legal and Ethical Topics in Surgery in Italy
  164. Cosmetic surgery: medicolegal considerations
  165. Focus on Medico-Legal and Ethical Topics in Surgery in Italy
  166. Voluntary termination of pregnancy (medical or surgical abortion): forensic medicine issues
  167. Review Article
  168. Role of Laparoscopic Splenectomy in Elderly Immune Thrombocytopenia
  169. Review Article
  170. Endoscopic diagnosis and treatment of neuroendocrine tumors of the digestive system
  171. Review Article
  172. Efficacy and safety of splenectomy in adult autoimmune hemolytic anemia
  173. Research Article
  174. Relationship between gastroesophageal reflux disease and Ph nose and salivary: proposal of a simple method outpatient in patients adults
  175. Case Report
  176. Idiopathic pleural panniculitis with recurrent pleural effusion not associated with Weber-Christian disease
  177. Research Article
  178. Morbid Obesity: treatment with Bioenterics Intragastric Balloon (BIB), psychological and nursing care: our experience
  179. Research Article
  180. Learning curve for endorectal ultrasound in young and elderly: lights and shades
  181. Case Report
  182. Uncommon primary hydatid cyst occupying the adrenal gland space, treated with laparoscopic surgical approach in an old patient
  183. Research Article
  184. Distraction techniques for face and smile aesthetic preventing ageing decay
  185. Research Article
  186. Preoperative high-intensity training in frail old patients undergoing pulmonary resection for NSCLC
  187. Review Article
  188. Descending necrotizing mediastinitis in the elderly patients
  189. Research Article
  190. Prophylactic GSV surgery in elderly candidates for hip or knee arthroplasty
  191. Research Article
  192. Diagnostic yield and safety of C-TBNA in elderly patients with lung cancer
  193. Research Article
  194. The learning curve of laparoscopic holecystectomy in general surgery resident training: old age of the patient may be a risk factor?
  195. Research Article
  196. Self-gripping mesh versus fibrin glue fixation in laparoscopic inguinal hernia repair: a randomized prospective clinical trial in young and elderly patients
  197. Research Article
  198. Anal sphincter dysfunction in multiple sclerosis: an observation manometric study
https://doi.org/10.1515/med-2016-0054
Keywords for this article
Informed consent; Surgery; Robotic surgery
Creative Commons
BY-NC-ND 3.0

Articles in the same Issue

  1. Research Article
  2. The possible molecular regulation mechanism of CIK cells inhibiting the proliferation of Human Lung Adenocarcinoma NCL-H157 Cells
  3. Case Report
  4. Urethral stone of unexpected size: case report and short literature review
  5. Case Report
  6. Complete remission through icotinib treatment in Non-small cell lung cancer epidermal growth factor receptor mutation patient with brain metastasis: A case report
  7. Research Article
  8. FPL tendon thickness, tremor and hand functions in Parkinson’s disease
  9. Research Article
  10. Diagnostic value of circulating tumor cells in cerebrospinal fluid
  11. Research Article
  12. A meta-analysis of neuroprotective effect for traditional Chinese medicine (TCM) in the treatment of glaucoma
  13. Research Article
  14. MiR-218 increases sensitivity to cisplatin in esophageal cancer cells via targeting survivin expression
  15. Research Article
  16. Association of HOTAIR expression with PI3K/Akt pathway activation in adenocarcinoma of esophagogastric junction
  17. Research Article
  18. The role of interleukin genes in the course of depression
  19. Case Report
  20. A rare case of primary pulmonary diffuse large B cell lymphoma with CD5 positive expression
  21. Research Article
  22. DWI and SPARCC scoring assess curative effect of early ankylosing spondylitis
  23. Research Article
  24. The diagnostic value of serum CEA, NSE and MMP-9 for on-small cell lung cancer
  25. Case Report
  26. Dysphonia – the single symptom of rifampicin resistant laryngeal tuberculosis
  27. Review Article
  28. Development of epidermal growth factor receptor tyrosine kinase inhibitors against EGFR T790M. Mutation in non small-cell lung carcinoma
  29. Research Article
  30. Negative regulation of CDC42 expression and cell cycle progression by miR-29a in breast cancer
  31. Research Article
  32. Expression analysis of the TGF-β/SMAD target genes in adenocarcinoma of esophagogastric junction
  33. Research Article
  34. Blood cells in thyroid cancer patients: a possible influence of apoptosis
  35. Research Article
  36. Detected EGFR mutation in cerebrospinal fluid of lung adenocarcinoma patients with meningeal metastasis
  37. Mini-review
  38. Pathogenesis-oriented approaches for the management of corticosteroid-resistant or relapsedprimary immune thrombocytopenia
  39. Research Article
  40. GSTP1 A>G polymorphism and chemosensitivity of osteosarcoma: A meta-analysis
  41. Research Article
  42. A meta-analysis of adiponectin gene rs22411766 T>G polymorphism and ischemic stroke susceptibility
  43. Research Article
  44. The diagnosis and pathological value of combined detection of HE4 and CA125 for patients with ovarian cancer
  45. Research Article
  46. SOX7 inhibits tumor progression of glioblastoma and is regulated by miRNA-24
  47. Research Article
  48. Sevoflurane affects evoked electromyography monitoring in cerebral palsy
  49. Case Report
  50. A case report of hereditary spherocytosis with concomitant chronic myelocytic leukemia
  51. Case Report
  52. A case of giant saphenous vein graft aneurysm followed serially after coronary artery bypass surgery
  53. Research Article
  54. LncRNA TUG1 is upregulated and promotes cell proliferation in osteosarcoma
  55. Review Article
  56. Meningioma recurrence
  57. Case Report
  58. Endobronchial amyloidosis mimicking bronchial asthma: a case report and review of the literature
  59. Case Report
  60. A confusing case report of pulmonary langerhans cell histiocytosis and literature review
  61. Research Article
  62. Effect of hesperetin on chaperone activity in selenite-induced cataract
  63. Research Article
  64. Clinical value of self-assessment risk of osteoporosis in Chinese
  65. Research Article
  66. Correlation analysis of VHL and Jade-1 gene expression in human renal cell carcinoma
  67. Research Article
  68. Is acute appendicitis still misdiagnosed?
  69. Retraction
  70. Retraction of: application of food-specific IgG antibody detection in allergy dermatosis
  71. Review Article
  72. Platelet Rich Plasma: a short overview of certain bioactive components
  73. Research Article
  74. Correlation between CTLA-4 gene rs221775A>G single nucleotide polymorphism and multiple sclerosis susceptibility. A meta-analysis
  75. Review Article
  76. Standards of anesthesiology practice during neuroradiological interventions
  77. Research Article
  78. Expression and clinical significance of LXRα and SREBP-1c in placentas of preeclampsia
  79. Letter to the Editor
  80. ARDS diagnosed by SpO2/FiO2 ratio compared with PaO2/FiO2 ratio: the role as a diagnostic tool for early enrolment into clinical trials
  81. Research Article
  82. Impact of sensory integration training on balance among stroke patients: sensory integration training on balance among stroke patients
  83. Review Article
  84. MicroRNAs as regulatory elements in psoriasis
  85. Review Article
  86. Influenza A(H1N1)pdm09 and postpandemic influenza in Lithuania
  87. Review Article
  88. Garengeot’s hernia: two case reports with CT diagnosis and literature review
  89. Research Article
  90. Concept of experimental preparation for treating dentin hypersensitivity
  91. Research Article
  92. Hydrogen water reduces NSE, IL-6, and TNF-α levels in hypoxic-ischemic encephalopathy
  93. Research Article
  94. Xanthogranuloma of the sellar region diagnosed by frozen section
  95. Case Report
  96. Laparoscopic antegrade cholecystectomy: a standard procedure?
  97. Case Report
  98. Maxillary fibrous dysplasia associated with McCune-Albright syndrome. A case study
  99. Regular Article
  100. Sialoendoscopy, sialography, and ultrasound: a comparison of diagnostic methods
  101. Research Article
  102. Antibody Response to Live Attenuated Vaccines in Adults in Japan
  103. Conference article
  104. Excellence and safety in surgery require excellent and safe tutoring
  105. Conference article
  106. Suggestions on how to make suboptimal kidney transplantation an ethically viable option
  107. Regular Article
  108. Ectopic pregnancy treatment by combination therapy
  109. Conference article
  110. Use of a simplified consent form to facilitate patient understanding of informed consent for laparoscopic cholecystectomy
  111. Regular Article
  112. Cusum analysis for learning curve of videothoracoscopic lobectomy
  113. Regular Article
  114. A meta-analysis of association between glutathione S-transferase M1 gene polymorphism and Parkinson’s disease susceptibility
  115. Conference article
  116. Plastination: ethical and medico-legal considerations
  117. Regular Article
  118. Investigation and control of a suspected nosocomial outbreak of pan-drug resistant Acinetobacter baumannii in an intensive care unit
  119. Regular Article
  120. Multifactorial analysis of fatigue scale among nurses in Poland
  121. Regular Article
  122. Smoking cessation for free: outcomes of a study of three Romanian clinics
  123. Regular Article
  124. Clinical efficacy and safety of tripterygium glycosides in treatment of stage IV diabetic nephropathy: A meta-analysis
  125. Special Issue on Italian Society for the Study of Vascular Anomalies
  126. Prevention and treatment of peritoneal adhesions in patients affected by vascular diseases following surgery: a review of the literature
  127. Special Issue on Italian Society for the Study of Vascular Anomalies
  128. Surgical treatment of recidivist lymphedema
  129. Special Issue on Italian Society for the Study of Vascular Anomalies
  130. CT and MR imaging of the thoracic aorta
  131. Special Issue on Italian Society for the Study of Vascular Anomalies
  132. Role of FDG-PET scan in staging of pulmonary epithelioid hemangioendothelioma
  133. Special Issue on Italian Society for the Study of Vascular Anomalies
  134. Sternal reconstruction by extracellular matrix: a rare case of phaces syndrome
  135. Special Issue on Italian Society for the Study of Vascular Anomalies
  136. Prenatal diagnosis, 3-D virtual rendering and lung sparing surgery by ligasure device in a baby with “CCAM and intralobar pulmonary sequestration”
  137. Special Issue on Italian Society for the Study of Vascular Anomalies
  138. Serum levels of inhibin B in adolescents after varicocelelectomy: A long term follow up
  139. Special Issue on Italian Society for the Study of Vascular Anomalies
  140. Our experience in the treatment of Malignant Fibrous Hystiocytoma of the larynx: clinical diagnosis, therapeutic approach and review of literature
  141. Special Issue on Italian Society for the Study of Vascular Anomalies
  142. Delayed recurrent nerve paralysis following post-traumatic aortic pseudoaneurysm
  143. Special Issue on Italian Society for the Study of Vascular Anomalies
  144. Integrated therapeutic approach to giant solitary fibrous tumor of the pleura: report of a case and review of the literature
  145. Special Issue on Italian Society for the Study of Vascular Anomalies
  146. Celiac axis compression syndrome: laparoscopic approach in a strange case of chronic abdominal pain in 71 years old man
  147. Special Issue on Italian Society for the Study of Vascular Anomalies
  148. A rare case of persistent hypoglossal artery associated with contralateral proximal subclavian stenosis
  149. Focus on Medico-Legal and Ethical Topics in Surgery in Italy
  150. Contralateral risk reducing mastectomy in Non-BRCA-Mutated patients
  151. Focus on Medico-Legal and Ethical Topics in Surgery in Italy
  152. Professional dental and oral surgery liability in Italy: a comparative analysis of the insurance products offered to health workers
  153. Focus on Medico-Legal and Ethical Topics in Surgery in Italy
  154. Informed consent in robotic surgery: quality of information and patient perception
  155. Focus on Medico-Legal and Ethical Topics in Surgery in Italy
  156. Malfunctions of robotic system in surgery: role and responsibility of surgeon in legal point of view
  157. Focus on Medico-Legal and Ethical Topics in Surgery in Italy
  158. Medicolegal implications of surgical errors and complications in neck surgery: A review based on the Italian current legislation
  159. Focus on Medico-Legal and Ethical Topics in Surgery in Italy
  160. Iatrogenic splenic injury: review of the literature and medico-legal issues
  161. Focus on Medico-Legal and Ethical Topics in Surgery in Italy
  162. Donation of the body for scientific purposes in Italy: ethical and medico-legal considerations
  163. Focus on Medico-Legal and Ethical Topics in Surgery in Italy
  164. Cosmetic surgery: medicolegal considerations
  165. Focus on Medico-Legal and Ethical Topics in Surgery in Italy
  166. Voluntary termination of pregnancy (medical or surgical abortion): forensic medicine issues
  167. Review Article
  168. Role of Laparoscopic Splenectomy in Elderly Immune Thrombocytopenia
  169. Review Article
  170. Endoscopic diagnosis and treatment of neuroendocrine tumors of the digestive system
  171. Review Article
  172. Efficacy and safety of splenectomy in adult autoimmune hemolytic anemia
  173. Research Article
  174. Relationship between gastroesophageal reflux disease and Ph nose and salivary: proposal of a simple method outpatient in patients adults
  175. Case Report
  176. Idiopathic pleural panniculitis with recurrent pleural effusion not associated with Weber-Christian disease
  177. Research Article
  178. Morbid Obesity: treatment with Bioenterics Intragastric Balloon (BIB), psychological and nursing care: our experience
  179. Research Article
  180. Learning curve for endorectal ultrasound in young and elderly: lights and shades
  181. Case Report
  182. Uncommon primary hydatid cyst occupying the adrenal gland space, treated with laparoscopic surgical approach in an old patient
  183. Research Article
  184. Distraction techniques for face and smile aesthetic preventing ageing decay
  185. Research Article
  186. Preoperative high-intensity training in frail old patients undergoing pulmonary resection for NSCLC
  187. Review Article
  188. Descending necrotizing mediastinitis in the elderly patients
  189. Research Article
  190. Prophylactic GSV surgery in elderly candidates for hip or knee arthroplasty
  191. Research Article
  192. Diagnostic yield and safety of C-TBNA in elderly patients with lung cancer
  193. Research Article
  194. The learning curve of laparoscopic holecystectomy in general surgery resident training: old age of the patient may be a risk factor?
  195. Research Article
  196. Self-gripping mesh versus fibrin glue fixation in laparoscopic inguinal hernia repair: a randomized prospective clinical trial in young and elderly patients
  197. Research Article
  198. Anal sphincter dysfunction in multiple sclerosis: an observation manometric study
Sign up now to receive a 20% welcome discount
Institutional Access
How does access work?
Have an idea on how to improve our website?
Please write us.
© 2025 De Gruyter Brill
Downloaded on 1.11.2025 from https://www.degruyterbrill.com/document/doi/10.1515/med-2016-0054/html
Scroll to top button