Robotic Surgery

Robotic surgery incorporates the latest advances in robotics, computing, and medical imaging. In the past few years, robotic surgery has made newspaper headlines and enjoyed a rapid rise in popularity. According to a 2005 BusinessWeek article, about 20,000 procedures were performed using robotic surgery in 2004, compared to just 1,500 procedures in 2000.

Robotic surgery falls into the broader field of minimally invasive surgery (MIS). MIS, also known as endoscopic surgery or keyhole surgery, was pioneered in 1987. Rather than cutting open and exposing the body cavity, small incisions, typically a few centimeters in length, are made. An endoscope – a long, flexible tube with a light and camera attached – is inserted into the body through one incision. Magnified video footage captured by the endoscope is broadcast on a television screen. Specialized instruments are then inserted through other incisions to perform the surgery. In robotic surgery, the surgeon does not wield any instruments directly. Instead, the instruments are mounted on robotic arms, and the surgeon controls the movement of these arms from a nearby console.

The da Vinci System

The da Vinci System from Intuitive Surgical is currently the most widely used surgical robot. It is incredibly versatile, and has been FDA approved for use in laparoscopic procedures (e.g., gallbladder removal), mitral valve operations, non-cardiac thoracoscopic surgeries, and prostatectomies.

The da Vinci system consists of three components: the vision system, the patient-side cart, and the surgeon console. The vision system includes the endoscope, the cameras, and other equipment to produce a 3D image of the operating field. The patient-side cart has three robotic arms and an optional fourth arm. One arm holds the endoscope, while the other arms hold interchangeable surgical instruments. The da Vinci system uses EndoWrist surgical instruments, which mimic the movements of the human hand and wrist. The surgeon carries out the entire operation seated at the console, where a viewing screen provides a 3D video of the operating field. Handheld controls translate the surgeon's hand, wrist, and finger movements to the two robotic arms, and foot pedals can also be used to adjust the robotic arms.

A newer model called the da Vinci S Surgical System is now available, and offers high definition imaging and other improvements.

Systems Under Development

Several promising robotic surgery systems are currently under development. NeuroArm, developed by the University of Calgary and MDA, promises to revolutionize brain surgery. This robotic surgery system is designed to be used in conjunction with real-time MRI, which can provide clear, 3D images of the smallest nerves and blood vessels. According to a 2007 New Scientist article, surgeons can visually track the operation's progress through a stereoscopic viewer and the real-time MRI image. Microphones located near the surgical instruments transmit the sounds of the operation to the surgeon's control room. Force-feedback handles allow surgeons to feel the pressure and texture of the tissues they are operating on, which prevents blood vessels and other tissues from being squeezed too hard. NeuroArm also allows grants surgeons a superhuman level of precision. In an April 2007 University of Calgary news release, philanthropist Doc Seaman said, "The best surgeons in the world can work within an eighth of an inch. NeuroArm makes it possible for surgeons to work accurately within the width of a hair." NeuroArm is currently awaiting approval from Health Canada before it can be used on human patients.

Traditional heart surgery is one of the most traumatic procedures, since it involves cracking open the chest, cutting through bones and muscle, deflating the left lung, and stopping the heart for the duration of the surgery. HeartLander, developed by the Robotics Institute at Carnegie Mellon University, hopes to make some heart surgeries a whole lot less painful. HeartLander, a tiny robot measuring just 20 millimeters, and can be inserted into the chest cavity through a tiny incision. Once in place, HeartLander can crawl across the beating heart, then inject drugs or attach medical devices at appropriate locations. According to a New Scientist article, the robot has already successfully fitted pacemakers in pigs. However, it will still be some time before HeartLander can be considered for human use.

Advantages of Robotic Surgery

Robotic surgery is minimally invasive, so patients benefit from shorter recovery times, less pain, and less scarring. In many cases, robotic surgery is an improvement over traditional MIS procedures. Robotic surgery systems offer a much clearer view inside the body than traditional endoscopic and laparoscopic techniques, since surgeons can magnify the operating field on their screen, and view images in 3D rather than 2D. The robotic wrists that hold surgical instruments can bend in ways that human wrists can't, and provide surgeons with greater dexterity and an increased range of motion. These features are especially helpful when working in confined spaces, and when operating on children and infants. Some systems offer motion scaling, where larger movements of the surgeon's hands are translated into smaller movements by the robotic instruments. For example, a four-centimeter movement by the surgeon can result in a one-centimeter movement by the robot. In some cases, such as with NeuroArm, motion scaling can allow surgeons to move with greater precision than is possible by hand. Robotic arms never experience fatigue or tremor. Since hand tremors naturally become more pronounced as people age, robotic surgery can potentially extend the working life of surgeons.

Robots have also ushered in the possibility of long-distance surgery, or telesurgery. The first transatlantic telesurgery took place in 2001, when surgeons in New York successfully removed the gallbladder of a woman in Strasbourg, France, using the ZEUS system. Although the surgeons and patient were an ocean apart, the surgeons' commands were carried out by the robot about one-tenth of a second later. In the future, telesurgery may enable surgeons to operate on patients who cannot travel, or allow surgeons in different locations to operate on the same patient.

Drawbacks of Robotic Surgery

Even experienced surgeons need additional training and practice before they can use a robotic surgery system. The FDA requires manufacturers of robotic surgical systems to provide training for surgeons, which typically involves several days of intensive training and practice on animals and cadavers. According to the BusinessWeek article, it usually takes surgeons 20 to 50 operations to become competent with the system. Surgeons also need to make a mental shift while working with robots. Rather than being able to see the patient directly, the surgeons must adjust to seeing the operating field on a screen. Tactile information is lost since the surgeon cannot directly feel the tissue that they're operating on, but the better visuals provided by robotic surgical systems can partly compensate for the loss.

A 2002 FDA article reported that some procedures performed with the da Vinci system took nearly twice as long as standard laparoscopic surgery. Longer surgeries limit the number of operations that can be performed on a given day, and also increases risks for the patient. However, most of the time difference was attributed to a lack of experience, and operating times with robotic systems are expected to approach those of conventional methods as the surgeons become more comfortable with the systems.

Robotic surgery systems are not fail-proof, and contingency plans must be in place in case of malfunctions. In the Robotic Surgery Blog, one urologist reported five malfunctions during 299 surgeries using the da Vinci system. According to the FDA article, there have been no patient injuries or deaths related to robotic system failures as of 2002.

All of this technology comes at a cost. The da Vinci Surgical System costs about US$1.5 million and requires about US$100,000 in annual upkeep. According to the BusinessWeek article, fewer than 300 hospitals worldwide had a da Vinci system in 2005. The article also states that using the da Vinci system adds about US$1,000 to the cost of a prostatectomy and about US$4,000 to the cost of a mitral valve operation. Proponents say that the higher costs of the operations are usually offset by the savings that result from shorter hospital stays and less pain medication. Opponents say that patient pressure may cause surgeons to choose robotic surgery over conventional methods, even when there is no clear medical advantage to doing so. In a 2005 WebMD article, Dr. Michael Argenziano, Director of Minimally Invasive Cardiac Surgery and Arrhythmia Surgery at New York-Presbyterian Hospital, opined that "Robotic surgery … can be a much bigger hit in the PR department than it is in the OR."

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