Robotic Surgery by Pier Cristoforo Giulianotti - Chicago, Illinois
Robotic Surgery refers to any surgical intervention carried out with a computerized technology which is able to reproduce the surgeon's hand movements within the human body or within any surgical field.
The da Vinci surgical systemThe da Vinci surgical system is made of three components:
- the surgeon’s console;
- the robotic cart, which hosts 4 robotic articulated arms (one of the scope and 3 for robotic instrument use) and is positioned over the patients operative table;
- a wheeled unit which mounts a monitor for the surgical team, the optic/light source and the CO2 insufflator. The latest da Vinci model (da Vinci Si) has an additional console which can host a second operating surgeon (normally a trainee surgeon, similar to the co-pilot within the aviation industry)
The surgeon at the console looks into the screen which reproduces a magnified high-definition three-dimensional image captured by the 2 cameras of the robotic scope which is introduced into the surgical field through a laparoscopic trocar.
The images are captured and reconstructed by a computer which delivers a perfect picture.
The surgeon’s hands manipulate the master controls (the console joysticks) which reproduce, upon software filtering, the movements on the robotic instrument.
The computer software improves the surgeon's movements which ameliorates his or her performance by decreasing tremor, increasing the scale of movements and, allowing regulation of the scale of movements between the masters and the robotic instruments according to the surgeon's preference.
The instruments connected to the robotic arms are interchangeable as per surgeon needs: forceps, scissors, clip applicator, different types of graspers, and ultrasound dissector are available.
The console, which for practical reasons is placed within the same operating room as the patient, is connected to the robotic cart via a fiber-optic cable.
Such connection could be potentially be made from longer distances (even a different hospital, city or country) and could be wireless in the future.
The only limitation is the delay between the image transmission and the surgeon motor response, which is considered safe if it remains lower than 200 milliseconds.
Verbal communication between the operating surgeon and surgical team take place directly or via a microphone system built into the console which can transmit to speakers in the operating theatre.
Should any problems arise during the robotic procedure, the surgical team at the operative table can disconnect the robot and carry on the procedure in a conventional manner (laparoscopically or open).
The conversion rate depends on the technical difficulty of the procedure as well as the experience of the robotic surgeon. The conversion rate varies between 1% on prostatic robotic procedures to 6-10% in pancreatic surgery.
The conversion for robotic equipment failure is an extremely rare event.
There is no robotic-specific morbidity other than those already known to be related to the laparoscopic approach.
Since 2000 more than 1 million robotic procedures have been carried out.
Clinical Applications of Robotic Surgery
Over the last decade robotic surgery has been shown to be feasible in many surgical procedure, expading the field of minimally invasive surgery. The spread of has been variable depending on various factors including cost-effectiveness and procedure specific learning curves.
Cardiac surgery, which pioneered the use of the robot, has found some difficulties. These were due to the fact that certain procedures such as single coronary by-pass have been overruled by angiographic stenting, whilst multiple coronary by-pass graftsing has been resulted technically difficult, especially with regards to accessing the posterior part of the heart. Despite these limitations, robotic surgery is finding its role in almost every other field of surgery.
Certain procedures, such as robotic prostatectomy, have boasted a very rapid growth and acceptance. In 2009, 80,000 robotic prostatectomies were carried out in the US. The oncological and functional results following robotic prostatectomy have been excellent; within the urology field, robotic surgery has gained acceptance for other procedures such as partial nephrectomies, cystectomies and pyeloplasties.
The second most common use of the robotic platform is gynecology. This technique gained acceptance among female patients due to its very favorable cosmetic results and among surgeons due to the ability to overcome difficulties of performing conventional laparoscopic surgery within the narrow pelvic space.
General surgery has had a more sluggish recognition of the benefits of robotic surgery. This is probably due to the fact that the abdomen in general represents a dynamic surgical field, this is in contrast with the premiere application of robotic procedures, which is within a narrow deep field (such as the pelvis). Another reason is that many procedures still have a viable alternative with the conventional laparoscopic surgery, in addition to the fact that the robotic platform is significantly more advantageous in complex procedures (hepatectomies, pancreatectomies) which are only carried out by a minority of general surgeons.
For such complex procedures the learning curve is extremely long and challenging; however the surgical results so far, demonstrate that surgical complications in esophageal, pancreatic and hepatic surgery are decreased, and that the robotic platform allows a larger number of surgeons to carry out a greater array of procedures in a minimally invasive fashion
Lately, colorectal surgery is gaining increasing popularity. Particularly, there are indications that the robotic treatment of rectal cancer has better results in the preservation of urinary and sexual function when compared to open and conventional laparoscopic surgery. In vascular surgery, the use of the robot has allowed minimally invasive repair of visceral aneurysms, which would otherwise have to be carried out in a highly invasive open fashion.
In endocrine surgery, beyond adrenalectomies, the robotic platform has been used for transaxillary thyroidectomies which avoids a conspicuous neck scar. Robotic thymectomy has also gained great popularity by avoiding an extremely invasive sternotomy. In otorhinolaryngology, transoral resections of mouth and upper respiratory mucosal lesions are being increasingly carried out in a robotic fashion. Even pediatric surgery is starting to consider robotic procedures within its armamentarium, and further advancements will be made with smaller dedicated robotic ports.
Prof. Pier Cristoforo Giulianotti - Chicago, Illinois
Lloyd Nyhus Professor of Surgery
Head and Chief, Division of Minimally Invasive and Robotic Surgery,
University of Illinois at Chicago
Vice-Head, Department of Surgery University of Illinois at Chicago
Program Director of General Surgery Fellowship Program, University of Illinois at Chicago