Robotic surgery: Improving patient outcomes and opening the door for telesurgery

The first time I came across the term ‘robotic surgery’, I imagined an android, much like C-3PO, performing heart or brain surgery in the operating room. However, I soon learned that this image was an inaccurate representation of robotic surgery. In reality, robotic surgery is the use of robotic intelligence to aid surgeons and enhance the way surgical procedures are performed. Robotics has been employed for medical procedures since the 1980s with the introduction of Puma 560, a device that was used to perform biopsies. 

Today, there are multiple different types of robotic surgery systems.  Two of the most commonly used systems are the Zeus and the da Vinci, which are comprised of a surgical console and a surgical cart with instrumentation arms. Both systems enable the main surgeon to sit at the console and control the instrumentation arms at the site of the operation. Some other features of these technologies are the da Vinci’s high definition 3-dimensional visualization of the operating field, and the voice-activated automated endoscopic surgical optimal positioning (AESOP) arm of Zeus (The Zeus system is no longer produced since its manufacturer merged with the da Vinci manufacturer, but it is still in use).

Robotic devices like Zeus and da Vinci have several advantages. The visualization system allows the surgeon to see the operating field in 3-dimensions with great depth and magnification. The instrumentation arms at the surgical cart are capable of performing fine movements with great range of motion. Computerized systems in the technology filter out shakes, tremors, and imprecise hand motions, making the surgical procedure smoother and more efficient.  The small size of the instruments allows for smaller incisions, faster healing, and lower infection rates.  In fact, a recent study found that in the case of prostate and kidney surgery, using robotic technology was associated with a lower risk of death or bleeding.  These advantages come at a great price, however.  The robotic instrumentation costs nearly $1.4 million dollars to purchase and $140,000 to maintain annually.  There is also a cost of $1,500 - $2,000 in disposable supplies per procedure.

Nevertheless, in hospitals with access to robotic surgical technology, it is employed in a variety of surgical procedures including pediatric surgery; gynecologic surgery; cardiothoracic surgery; Ear, Nose and Throat (ENT); and urology.  In 2010 alone, 98,000 robotic-assisted radical prostatectomies (removal of the prostate gland) were performed.  In addition, robot-assisted surgery has been used for nephrectomies (removal of the kidney) and kidney transplantation.  Head and neck surgery has also made strides as a result of robotic surgery where robotic systems have been used to perform trans-oral surgery of the oropharynx.  Transoral robotic surgery of the larynx as well as minimally invasive thyroid surgery is also being investigated by ENT surgeons.  In cardiothoracic surgery, robotic technology has been employed for coronary artery bypass as well as valve repair.  Furthermore, last week surgeons at Toronto General Hospital reported using the da Vinci system to remove a cancerous lung lobe from a patient.

Morover, robotic surgery has implications for the field of telesurgery.  In 2001, surgeons in New York performed the first remote surgical procedure, a robotic cholecystectomy (gall bladder removal) on a patient in France, using robotic technology and sophisticated high-speed communication systems.  Canada has been at the forefront of telesurgery; Dr. Mehran Anvari, the founder of the Center for Minimal Access Surgery, has performed surgical procedures from Hamilton, Ontario on patients in rural hospitals hundreds of kilometers away.  The future of telesurgery is promising, as surgeons may one day be able to remotely perform operations on patients in areas with limited access to surgeons.  In addition, telesurgery enables wounded soldiers to receive immediate surgical care from a remotely situated surgeon.  For this reason, in the 1990s, the department of defense invested a significant amount into research on robotic surgery.  Another potential use of telesurgery is in training surgeons from a remote location.  Shortages of specialist surgeons is a major problem in the developing world; it may be possible for trainees to receive advanced surgical training in their home countries from experts in North America and Europe using robotic technology.  As the field of telesurgery expands, the legal and administrative implications will become an issue of interest.  For example, if a surgeon in one country is controlling a robot-assisted device in another country, how will national medical licensure laws be applied? 

In the meantime, research in the field of robotic surgery is rapidly advancing thanks to greater collaboration between different academic institutions.  Researchers at the University of California Santa, Cruz and the University of Washington recently reported offering a new robotic surgical system known as the Raven II -- which was developed using funding from the National Science Foundation -- to major research centers at five institutions.  They state that they have employed an “open source model” for the sharing of this technology to enable simultaneous collaborations at leading institutions in the field of robotic surgery.  According to Dr. Jacob Rosen at UC Santa Cruz, access to this technology at large academic institutions has been limited, making it difficult to perform studies.  They hope that the new collaborative approach will enable experts to study these systems more thoroughly and examine patient outcomes of robotic surgery more extensively.  Other advances in robotic surgery are also being examined and include making the surgical arms smaller for finer surgery, as well as the development of instruments that can sense different structures and employ feedback mechanisms. 

As the field of robotic surgery continues to advance it will be interesting to consider how residency programs will incorporate this technology into their training curricula. Currently it is reported that 7 percent of hospitals in the United States have da Vinci systems in their hospitals, but as hospitals continue to adopt this and other robotic technologies at a rapid pace, training of residents and fellows in robotic surgery will become more relevant.  Some experts argue that as robotic surgery becomes more widespread, residency programs should incorporate competencies in this area into their curricula and ensure that residents have performed sufficient surgeries using robotic technology. We are still a long ways away from an android like C-3PO performing surgery by itself.  But the advent of robots will change the surgical experience for surgeons and patients alike.  And it will give surgeons, engineers, and other scientists plenty to work on as they further develop the field of robotic surgery and understand its benefits and drawbacks. 

References

Y. Kakeji, et al. Robotic laparoscopic distal gastrectomy:
a comparison of the da Vinci and Zeus systems.  International Journal of Medical Robotics and Computer Assisted Surgery, 2006; 2: 299–304

Newman JG, et al. Robotics and Telesurgery in Otolaryngology.  Otolaryngology Clinics of North America, 44 (2011) 1317–1331

Orvieto MA, et al. Robotic technologies in surgical oncology training and practice. Surgical Oncology, 20 (2011) 203–209