A Practical Approach to Robotic Surgery Ajit Saxena
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1Robot and Surgery
  • Robotic Surgery: Past, Present and Future
    Naresh Trehan
  • Ergonomics
    Megha Bhatnagar, Aditi Midha
  • Immunofluorescence and Robotic Surgery
    Vivek Bindal, Anand Kumar Yadav
  • Anesthesia
    Sangeeta Khanna, Jyotirmoy Das, Yatin Mehta2

Robotic Surgery: Past, Present and FutureCHAPTER 1

Naresh Trehan
Robotic surgery and robotically assisted surgical procedures are newer technological developments in the field of minimally invasive surgical procedures, which enhance the capability of a surgeon. A surgeon can control the robotic instruments directly by a remote manipulator like telemanipulator or through the computer during any minimal invasive robotic surgery.
Robotic surgeries carry higher accuracy, small incision, less blood loss, decreased pain and early healing. Major advances in robotic surgery now offer three-dimensional view of surgical field with magnification.
During robotic surgeries, the surgeon need not have to stand throughout the duration of procedure and will not get tired easily. The hand tremors can be filtered out by the robot. The surgical robotic system can work continuously and easily used by different surgical teams in shifts.
The da Vinci system is a surgical robot which is Food and Drug Administration (FDA) approved. Robotic surgeries on the heart, gastrointestinal tract, kidney, urethra, prostate can be carried out using the da Vinci system.
The US FDA has also approved Zeus surgical system, which has three robotic arms. The Automated Endoscopic System for Optimal Positioning (AESOP) Robotic System is a robotic arm which can respond to voice commands and hold endoscope.
Robotic surgery is evolving as a significantly promising newer technology and considered revolutionary by many. However, this emerging field of robotic surgery has been sometimes, criticized by considering the facts that robots are expensive and market driven.
The earliest robotic surgery dates back to 1983 when orthopedic robotic surgery was conducted with the help of robot named the “Arthrobot”. A robot called PUMA 560 was used for neurosurgical biopsy in 1985. At Imperial College, London, a robotic surgery on prostate was conducted in 1985 by the robotic system PROBOT. PROBOT was specifically designed for transurethral resection of prostate. Another robotic system named ROBDOC was designed to assist hip replacement surgeries in 1992.
Various organizations such as Intuitive Surgical and Computer Motion made more development of systems associated with robotic surgeries. They introduced da Vinci Surgical System and ZEUS robotic surgical systems.
The da Vinci Surgical System consists of three components. They are console for the surgeon, robotic cart containing four arms (one for the camera and other three arms for instruments) and a high definition three-dimensional vision system.
Towards the end of 1980s the minimally invasive surgery (MIS) or minimal access surgery became famous and revolutionized the concept by inserting the instruments in body by making small incisions.
In 1990s, the laparoscopic revolution happened and many surgical procedures were changed from traditionally done open surgeries to minimal access procedures. Even though there was decrease in collateral surgical trauma, there were inherent problems which included difficult wrist articulation, no tremor filtration, fulcrum effects, loss of three dimensional vision and poor ergonomics. Many of these were eliminated when robotic surgery evolved and made a transit from laparoscopy. Robotic surgery slowly emerged as effective procedure which could address the limitations of laparoscopic operations.
Clinical Applications
Robotic surgery has been conducted for many male and female patients for varieties of indications in different age groups. In pediatric patients, robotic surgery may be beneficial for Kasai procedure in biliary atresia, choledochal cyst repair and tumor excisions and reconstructive procedures in thoracic or abdominal region.
In gynecological surgeries, the Robotic procedures had shown good results in patients who had undergone hysterectomy and myomectomy. Robotic surgery has been 4considered beneficial in cases of tubal reconstruction and pelvic reconstruction procedures.
In general surgery, robotic surgery has been applied for antireflux procedures, cholecystectomy, gastroplasty surgery for obesity, hernia repair and colorectal procedures. Robotic surgery is mostly suitable for conditions affected in one quadrant of the abdomen, which has challenging access.
Robotic surgery is considered advantageous in urological procedures, which are minimally invasive. Better outcomes in robotic surgery have been seen in patients who had undergone robotic radical prostatectomy, robotic radical cystectomy, pyeloplasty, partial or complete nephrectomy and ureteral reimplantation.
In cardiovascular surgeries with robotic assistance, encouraging results have been shown in patients who had undergone robotic-assisted coronary bypass grafting and mitral valve repair.
In otorhinolaryngology, patients requiring transoral oncologic resections of tumors in the area of pharynx or larynx have benefited from robotic surgery.
Current Robotic Surgery Set-up and Technique
Commonly used surgical robot is the da Vinci surgical system which is approved by the FDA since 2000. The da Vinci robotic surgical platform uses four overhead arms. The da Vinci robotic instruments have longer shafts and the endoscope which has a camera built into its distal tip (Fig. 1.1).
The da Vinci Xi system follows a standardized approach for positioning of the robot over the camera port and then targeting of the camera is done before docking of the remaining robotic ports. The robotic camera easily fits into the 8 mm trocar which allows its insertion into any of the four robotic arms.
The Zeus system consists of a surgeon control console and three table-mounted robotic arms. The robotic arms present on right and left side can replicate the right and left arm of the robotic surgeon. The third arm is a voice-controlled robotic endoscope used for better visualization (AESOP).
zoom view
Fig. 1.1: da Vinci robotic surgery set-up
Current Robotic Systems
Many robotic systems had been approved by the US FDA for specific surgeries. ROBODOC was used in past to core out femur during hip replacement operation. The Zeus and the da Vinci system had been used by several surgical disciplines which include gallbladder surgeries, cardiac valve repair, radical prostate surgery, reversing the tubal ligations, gastro-intestinal operations, nephrectomy, and renal transplant. Day-by-day many institutions are procuring these robotic systems to perform many types of surgery including coronary artery grafting with less morbidity.
Robotic surgeries are highly beneficial in cases of intra-abdominal microsurgery where manipulations are done in very small spaces. Since early 2000 general surgical interventions such as esophageal and pancreatic surgery were done with the help of da Vinci device. Currently commonly done cardiac surgeries are septal defect repairs, valve repairs and coronary artery bypass. Robotic colorectal surgeries are being done in many of malignant colon and rectal lesions. There is better visualization of pelvic nerves during robotic surgery and less chance of nerve injury by which many postoperative complications of impotence or incontinence are avoided. In urology, robotic surgeries are most popular. Robotic surgical procedures are mostly done for surgery of kidney, prostate and urinary bladder cancers due to difficultly in accessing the anatomical structures.
Current Robotic Surgery Advantages
The robotic systems recently available have instruments which offer higher degrees of freedom to enhance the surgeon's capacity to manipulate. Robotic systems are designed to compensate tremors by hardware or software filters.
The robotic system can reduce the fulcrum effect by making the instrument manipulations intuitive and avoids twists or turns from awkward position.
Currently robotic surgery has proven itself to be of significant value, particularly in inaccessible places in comparison to conventional procedures. Robotic surgeries are safe operations with decreased morbidity. Robotic surgeries had given significant benefits to patients by decreased blood loss and transfusions, less pain, short hospital stay of patients and faster recovery. The minimally invasive robotic approach has slowly becoming a standard of care for many small size tumors.
Robotic surgeries involve the use of a sophisticated robotic device (known as the da Vinci Surgical Robotic System) with wristed instrumentation to permit the surgeon to dissect while controlling these instruments from a surgeon console externally.
Most of the recent advantages in robotic surgeries ensure its development and continued expansion. Currently, the 5sophisticated control and multiple degrees of freedom provided by Zeus and da Vinci systems offer greater mobility and no tremor without any compromise in visual field.
A study by Cadiere et al. evaluated the feasibility of robotic surgeries in 146 patients. Robotic surgeries were done with help of a da Vinci robot, which included thirty-nine antireflux operations, fortyeight cholecystectomies, twenty-eight tubal re-anastomoses, ten gastroplasties in obese patient, three inguinal hernia repairs, three intrarectal operations, two hysterectomies, two cardiac operations, two prostatectomies, two AV fistulas, one lumbar sympathectomy, one appendectomy, one laryngeal exploration, one varicocele procedure, one endometriosis and one neosalpingostomy. The study found that the robotic surgeries will be most effective in abdominal microsurgery or for manipulations in small spaces.1
Damiano et al. had conducted a multicenter clinical trial on robotic-assisted coronary artery bypass grafting. The study had 32 patients scheduled for primary coronary surgery who underwent endoscopic anastomosis of the left internal thoracic artery to left anterior descending artery. Two-month follow up revealed a graft patency of 93%. The study had opined that robotic-assisted coronary bypass grafting as feasible procedure.2
In a study Mohr et al. used the da Vinci system to conduct coronary artery bypass graft procedure on 131 patients and repair of diseased mitral valve on 17 patients. They concluded that robotic systems can be used safely in patients to perform robotic cardiac surgery.3
Many people imagine that robotics is all about automation. In future robotic systems, there might be chance for a surgeon to program the procedure and simply supervise while the robot performs the surgery.
The robotic surgical procedures are expected to play crucial roles in future. Hence there should be emphasis on training of robotic surgery in residency or postgraduation courses for surgeons in academic centers.
There are advances happening in robotic surgery in areas of new tissue anastomosis procedures, improved robotic instruments and digitally integrating the existing robotic technologies in many disciplines of surgery.
In future, there is a possibility that there could be fusion of images from CT scan or MRI during surgery and before surgery to help the surgeon to identify the pathology and dissect.
In future, the data can be stored to rehearse any complex robotic operation and make long distance consultation and assessments. The advances in computer graphics (CG) and simulation technology aided by computers will take robotic surgeries to a new level.
Next generation of robotic technology will involve non-contact tools during navigating or intervention. The robotic surgery will be scarless in future with help of laser scalpel. Mobile robots may be introduced in future for monitoring postoperative condition of a patient.
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