Robotic Surgery Robotic surgery is one of the most exciting and promising areas in the field of minimally invasive surgery.

The past two decades have witnessed a revolutionary transition in surgical technique and technology. Traditionally, surgeries had been performed in the open manner, in which large incisions were required for the surgeon to plainly observe and manipulate the surgical field.

These incisions inevitably created significant patient trauma (substantial pain and suffering), extended recovery time, prolonged pain management and elevated costs.

 

Minimally Invasive Surgery (MIS)

Approximately 20 years ago, surgeons began practicing a new approach to performing surgery, an approach that came to be known as minimally invasive surgery, or MIS. During this era, tiny cameras in instruments called endoscopes or laparoscopes were introduced. These visual and surgical aids could be inserted in the patient's body through small ports.

 

Robotic Assisted SurgeryAlthough revolutionary in its positive effect on patient trauma and recovery times, MIS encountered significant technical drawbacks. The surgeon operated using a standard 2D monitor instead of looking at his or her hands. The resulting image flattened the natural depth of field, and the fixed-wrist instruments limited his/her dexterity. The lack of 3D visualization of the operative field, the poor ergonomic design and reduced control were major roadblocks to further progress. As a result, this type of MIS turned out to be suitable for a narrow range of surgical procedures.

 

Three major advances aided by surgical robots have been remote surgery, minimally invasive surgery and unmanned surgery. Major advantages of robotic surgery are precision, miniaturization, smaller incisions, decreased blood loss, less pain, and quicker healing time. Further advantages are articulation beyond normal manipulation and three-dimensional magnification.

 

History

In 1985 a robot, the PUMA 560, was used to place a needle for a brain biopsy using CT guidance.  In 1988, the PROBOT, developed at Imperial College London, was used to perform prostatic surgery.

The ROBODOC from Integrated Surgical Systems was introduced in 1992 to mill out precise fittings in the femur for hip replacement. Further development of robotic systems was carried out by Intuitive Surgical with the introduction of the da Vinci Surgical System and Computer Motion with the AESOP and the ZEUS robotic surgical system. (Intuitive Surgical bought Computer Motion in 2003; ZEUS is no longer being actively marketed.)

 

  • In 1997 a reconnection of the fallopian tubes operation was performed successfully in Cleveland using ZEUS.
  • In May 1998, Dr. Friedrich-Wilhelm Mohr using the Da Vinci surgical robot performed the first robotically assisted heart bypass at the Leipzig Heart Centre in Germany.
  • On 2 September 1999, Dr. Randall Wolf and Dr. Robert Michler performed the first robotically assisted heart bypass in the USA at The Ohio State University.
  • In October 1999 the world's first surgical robotics beating heart coronary artery bypass graft (CABG) was performed in Canada using the ZEUS surgical robot.
  • In 2001, Prof. Marescaux used the "Zeus" robot to perform a cholecystectomy on a pig in Strasbourg, France while in New York.
  • In September 2001, Dr. Michel Gagner used the Zeus robotic system to perform a cholecystectomy on a woman in Strasbourg, France while in New York.
  • The first unmanned robotic surgery took place in May 2006 in Italy.

Robotic-assisted surgery

 

The da Vinci Surgical System comprises three components: a surgeon's console, a patient-side robotic cart with 4 arms manipulated by the surgeon (one to control the camera and three to manipulate instruments), and a high-definition 3D vision system. Articulating surgical instruments are mounted on the robotic arms which are introduced into the body through cannulas. The surgeon's hand movements are scaled and filtered to eliminate hand tremor then translated into micro-movements of the proprietary instruments. The camera used in the system provides a true stereoscopic picture transmitted to a surgeon's console. The da Vinci System is FDA cleared for a variety of surgical procedures including surgery for prostate cancer, hysterectomy and mitral valve repair, and is used in more than 800 hospitals in the Americas and Europe. The da Vinci System is used in over 45,000 procedures a year and sells for about £1.6 million.(2008 UK)

 

Although the general term "robotic surgery" is often used to refer to the technology, this term can give the impression that the robot is performing the surgery. In contrast, the robot cannot - in any manner - run on its own. Instead, the System is designed to seamlessly replicate the movement of the surgeon's hands with the tips of micro-instruments. The System cannot make decisions, nor can it perform any type of movement or maneuver without the surgeon's direct input.The da Vinci System could potentially be used to perform truly remote operations. The possibility of long distance operations depend on the patient having access to a da Vinci System and someone to put in the ports, but technically the system could allow a doctor in the United States, for example, to do surgery on a patient in Antarctica. The da Vinci Surgical System can theoretically be used to operate over long distances. According to the manufacturer, this capability, however, is not the primary focus of the company and thus is not available with the current da Vinci Surgical System.

 

Applications

 

General surgery

Many general surgical procedures can now be performed using the state of the art robotic surgical system. In 2007, the University of Illinois at Chicago medical team, lead by Prof. Pier Cristoforo Giulianotti, performend the world's first ever robotic pancreatectomy and also the Midwests fully robotic Whipple surgery, which is the most complicated and demanding procedure of the abdomen. In April 2008, the same team of surgeons performed the world's first fully minimally invasive liver resection for living donor transplantation, removing 60% of the patient's liver, yet allowing him to leave the hospital just a couple of days after the procedure, in a very good condition.

 

Cardiothoracic surgery

Robot-assisted MIDCAB and Endoscopic coronary artery bypass (TECAB) surgery are being performed with the da Vinci system. Mitral valve repairs and replacements have been performed. East Carolina University, Greenville(Dr W. Randolph Chitwood), Saint Joseph's Hospital, Atlanta(Dr Douglas A. Murphy), and Good Samaritan Hospital, Cincinnati(Dr J. Michael Smith) have popularized this procedure and proved its durability with multiple publications. Since the first robotic cardiac procedure performed in the USA in 1999, The Ohio State University, Columbus(Dr. Juan Crestanello, Dr. Paul Vesco) has performed CABG, mitral valve, esophagectomy, lung resection, tumor resections, among other robotic assisted procedures and serves as a training site for other surgeons. The University of Chicago, (Dr. Sudhir Srivastava) has performed a number of the TECAB procedures and was recently featured in the USA Today on 30 April 2008.

 

Cardiology and electrophysiology

The Stereotaxis Magnetic Navigation System (MNS) has been developed to increase precision and safe in ablation procedures for arrhythmias and atrial fibrillation while reducing radiation exposure for the patient and physician, and the system utilizes two magnets to remotely steer catheters. The system allows for automated 3-D mapping of the heart and vasculature, and MNS has also been used in interventional cardiology for guiding stents and leads.

 

Gastrointestinal surgery

Multiple types of procedures have been performed with either the Zeus or da Vinci robot systems, including bariatric surgery.

 

Gynecology

Robotic surgery in gynecology is one of the fastest growing fields of robotic surgery. This includes the use of the da Vinci surgical system in benign gynecology and gynecologic oncology. Robotic surgery can be used to treat fibroids, abnormal periods, endometriosis, ovarian tumors, pelvic prolapse, and female cancers. Using the robotic system, gynecologists can perform hysterectomies, myomectomies, and lymph node biopsies. The need for large abdominal incisions is virtually eliminated.

 

Neurosurgery

Several systems for stereotactic intervention are currently on the market. MD Robotic's NeuroArm is the world's first MRI-compatible surgical robot.

 

Orthopedics

The ROBODOC system was released in 1992 by the Integrated Surgical Systems, Inc.

 

Pediatrics

Surgical robotics has been used in many types of pediatric surgical procedures including: tracheoesophageal fistula repair, cholecystectomy, nissen fundoplication, morgagni hernia repair, kasai portoenterostomy, congenital diaphragmatic hernia repair, and others. On January 17, 2002, surgeons at Children's Hospital of Michigan in Detroit performed the nation's first advanced computer-assisted robot-enhanced surgical procedure at a children's hospital.

 

Radiosurgery

The CyberKnife Robotic Radiosurgery System uses image-guidance and computer controlled robotics to treat tumors throughout the body by delivering multiple beams of high-energy radiation to the tumor from virtually any direction.

 

Urology

The da Vinci robot is commonly used to remove the prostate gland for cancer, repair obstructed kidneys, repair bladder abnormalities and remove diseased kidneys. New minimally invasive robotic devices using steerable flexible needles are currently being developed for use in prostate brachytherapy. A few leading urologists in the field of robotic urological surgery are Drs. Ashutosh Tewari, Mani Menon, Patrick Walsh, Peter Schlegel, Douglas Scherr and Darracott Vaughan.

 

Limitations

Current equipment is expensive to obtain, maintain and operate. If one of the older model non-autonomous robots is being used, surgeons and staff need special training. Data collection of procedures and their outcomes remains limited.

 

Miniature robotics

As scientists seek to improve the versatility and utility of robotics in surgery, some are attempting to miniaturize the robots. For example, the University of Nebraska Medical Center has led a multi-campus effort to provide collaborative research on mini-robotics among surgeons, engineers and computer scientists. Scientists at Hebrew University have also developed a miniature robot to navigate through the bloodstream.

 

Paediatric robotics

The Center for Robotic Surgery at Children's Hospital Boston provides a high level of expertise in pediatric robotic surgery. Specially-trained surgeons use a high-tech robot to perform complex and delicate operations through very small surgical openings. The results are less pain, faster recoveries, shorter hospital stays, smaller scars, and happier patients and families. In 2001, Children's Hospital Boston was the first pediatric hospital to acquire a surgical robot. Today, surgeons use the technology for many procedures and perform more pediatric robotic surgeries than any other hospital in the world. Children's Hospital physicians have developed a number of new applications to expand the use of the robot, and train surgeons from around the world on its use.

 

Sources:

http://www.fda.gov/fdac/features/2005/405_computer.html

http://www.intuitivesurgical.com/products/fdaclearance/index.aspx

http://en.wikipedia.org/wiki/Robotic_surgery

http://www.childrenshospital.org/clinicalservices/Site1860/mainpageS1860P5.html

http://www.intuitivesurgical.com/corporate/newsroom/videos/da_vinci_s_hd_technical_owv.aspx

 

Compiled by John Sandham

Dec 2008

 

 

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