Robot-assisted surgery

Robot-assisted surgery or robotic surgery are any types of surgical procedures that are performed using robotic systems. Robotically assisted surgery was developed to try to overcome the limitations of pre-existing minimally-invasive surgical procedures and to enhance the capabilities of surgeons performing open surgery.

In the case of robotically assisted minimally-invasive surgery, instead of the surgeon directly moving the instruments, the surgeon uses one of two methods to perform dissection, hemostasis and resection, using a direct telemanipulator, or through computer control.

Memory devices play an essential role in preventing any inconveniences in the robot-assisted surgery. The memory storage solutions can perform multiple functions based on the patient's physical record. They can also indicate specific information to measure calibration offsets indicating misalignment of the storage drive system, life of the data, and so on.

Robotic surgery has been criticized for its expense, with the average costs in 2007 ranging from $5,607 to $45,914 per patient.

History

The concept of using standard hand grips to control manipulators and cameras of various sizes down to sub-miniature was described in the Robert Heinlein story 'Waldo' in August 1942, which also mentioned brain surgery. The first robot to assist in surgery was the Arthrobot, which was developed and used for the first time in Vancouver in 1984.

In 1985 a robot, the Unimation Puma 200, was used to orient a needle for a brain biopsy while under CT guidance during a neurological procedure.

Further development of robotic systems was carried out by SRI International and Intuitive Surgical with the introduction of the da Vinci Surgical System and Computer Motion with the AESOP and the ZEUS robotic surgical system.

AESOP was a breakthrough in robotic surgery when introduced in 1994, as it was the first laparoscopic camera holder to be approved by the FDA. NASA initially funded the company that produces AESOP, Computer Motion, due to its goal to create a robotic arm that can be used in space, but this project ended up becoming a camera used in laparoscopic procedures. Voice control was then added in 1996 with the AESOP 2000 and seven degrees of freedom to mimic a human hand was added in 1998 with the AESOP 3000.

ZEUS was introduced commercially in 1998, and started the idea of telerobotics or telepresence surgery where the surgeon is at a distance from the robot on a console and operates on the patient.

The original telesurgery robotic system that the da Vinci was based on was developed at Stanford Research Institute International in Menlo Park with grant support from DARPA and NASA.

In 2005, a surgical technique was documented in canine and cadaveric models called the transoral robotic surgery (TORS) for the da Vinci robot surgical system as it was the only FDA-approved robot to perform head and neck surgery.

On 12 May 2008, the first image-guided MR-compatible robotic neurosurgical procedure was performed at University of Calgary by Dr. Garnette Sutherland using the NeuroArm.

In 2019 the Versius Surgical Robotic System was launched and is a rival of the Da Vinci surgical system and claims to be more flexible and versatile, having independent modular arms which are "quick and easy to set up". The small-scale design means that it is suitable for virtually any operating room and can be operated at either a standing or a sitting position.

Uses

Ophthalmology

Ophthalmology is still part of the frontier for robotic-assisted surgeries. However, there are a couple of robotic systems that are capable of successfully performing surgeries.

Heart

Some examples of heart surgery being assisted by robotic surgery systems include:

Thoracic

Robotic surgery has become more widespread in thoracic surgery for mediastinal pathologies, pulmonary pathologies and more recently complex esophageal surgery.

The da Vinci Xi system is used for lung and mediastinal mass resection. This minimally invasive approach as a comparable alternative to video-assisted thoracoscopic surgery (VATS) and the standard open thoracic surgery. Although VATS is the less expensive option, the robotic-assisted approach offers benefits such as 3D visualizations with seven degrees of freedom and improved dexterity while having equivalent perioperative outcomes.

ENT

The first successful robot-assisted cochlear implantation in a person took place in Bern, Switzerland in 2017.

Advantages of robot-assisted cochlear implantation include improved accuracy,

Challenges that still need to be addressed include safety, time, efficiency and cost.

Surgical robots have also been shown to be useful for electrode insertion with pediatric patients.

Gastrointestinal

Multiple types of procedures have been performed with either the 'Zeus' or da Vinci robot systems,

Robot-assisted pancreatectomies have been found to be associated with "longer operating time, lower estimated blood loss, a higher spleen-preservation rate, and shorter hospital stay

Gynecology

The first report of robotic surgery in gynecology was published in 1999 from the Cleveland Clinic.

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, uterine prolapse, and female cancers.

A 2017 review of surgical removal of the uterus and cervix for early cervical cancer robotic and laparoscopic surgery resulted in similar outcomes with respect to the cancer.

Bone

Robots are used in orthopedic surgery.

ROBODOC is the first active robotic system that performs some of the surgical actions in a total hip arthroplasty (THA). It is programmed preoperatively using data from computer tomography (CT) scans. This allows for the surgeon to choose the optimal size and design for the replacement hip.

Acrobot and Rio are semi-active robotic systems that are used in THA. It consists of a drill bit that is controlled by the surgeon however the robotic system does not allow any movement outside the predetermined boundaries.

Mazor X is used in spinal surgeries to assist surgeons with placing pedicle screw instrumentation. Inaccuracy when placing a pedicle screw can result in neurovascular injury or construct failure. Mazor X functions by using templating imaging to locate itself to the target location of where the pedicle screw is needed.

Spine

Robotic devices started to be used in minimally invasive spine surgery starting in the mid-2000s.

As of 2019, the application of robotics in spine surgery has mainly been limited to pedicle screw insertion for spinal fixation.

Transplant surgery

The first fully robotic kidney transplantations were performed in the late 2000s. It may allow kidney transplantations in people who are obese who could not otherwise have the procedure.

General surgery

With regards to robotic surgery, this type of procedure is currently best suited for single-quadrant procedures,

Hernia and Abdominal Wall Surgery

Over the past several decades, there have been great advances in the field of abdominal wall and hernia surgery especially when it comes to robotic-assisted surgery. Unlike laparoscopic surgery, the robotic platform allows for the correction of large hernia defects with specialized techniques that would traditionally only be performed via an open approach. Compared to open surgery, robotic surgery for hernia repair can reduce pain, length of hospital stay, and improve outcomes.

The first robotic inguinal hernia repairs were done in conjunction with prostatectomies in 2007.

With newer techniques such as direct access into the abdominal wall,

Urology

Robotic surgery in the field of urology has become common, especially in the United States.

There is inconsistent evidence of benefits compared to standard surgery to justify the increased costs.

In 2000, the first robot-assisted laparoscopic radical prostatectomy was performed.

Robotic surgery has also been utilized in radical cystectomies. A 2013 review found less complications and better short term outcomes when compared to open technique.

Pediatrics

Pediatric procedures are also benefiting from robotic surgical systems. The smaller abdominal size in pediatric patients limits the viewing field in most urology procedures. The robotic surgical systems help surgeons overcome these limitations. Robotic technology provides assistance in performing

Comparison to traditional methods

Major advances aided by surgical robots have been remote surgery, minimally invasive surgery and unmanned surgery. Due to robotic use, the surgery is done with precision, miniaturization, smaller incisions; decreased blood loss, less pain, and quicker healing time. Articulation beyond normal manipulation and three-dimensional magnification help to result in improved ergonomics. Due to these techniques, there is a reduced duration of hospital stays, blood loss, transfusions, and use of pain medication.

The robot's costs range from $1 million to $2.5 million for each unit,

Compared with other minimally invasive surgery approaches, robot-assisted surgery gives the surgeon better control over the surgical instruments and a better view of the surgical site. In addition, surgeons no longer have to stand throughout the surgery and do not get tired as quickly. Naturally occurring hand tremors are filtered out by the robot's computer software. Finally, the surgical robot can continuously be used by rotating surgery teams.

There are some issues in regards to current robotic surgery usage in clinical applications. There is a lack of haptics in some robotic systems currently in clinical use, which means there is no force feedback, or touch feedback. No interaction between the instrument and the patient is felt. However, recently the Senhance robotic system by Asensus Surgical was developed with haptic feedback in order to improve the interaction between the surgeon and the tissue.

The robots can also be very large, have instrumentation limitations, and there may be issues with multi-quadrant surgery as current devices are solely used for single-quadrant application.

Critics of the system, including the American Congress of Obstetricians and Gynecologists,

Complications related to robotic surgeries range from converting the surgery to open, re-operation, permanent injury, damage to viscera and nerve damage. From 2000 to 2011, out of 75 hysterectomies done with robotic surgery, 34 had permanent injury, and 49 had damage to the viscera.

One drawback of the use of robotic surgery is the risk of mechanical failure of the system and instruments. A study from July 2005 to December 2008 was conducted to analyze the mechanical failures of the da Vinci Surgical System at a single institute. During this period, a total of 1797 robotic surgeries were performed used 4 da Vinci surgical systems. There were 43 cases (2.4%) of mechanical failure, including 24 (1.3%) cases of mechanical failure or malfunction and 19 (1.1%) cases of instrument malfunction. Additionally, one open and two laparoscopic conversions (0.17%) were performed. Therefore, the chance of mechanical failure or malfunction was found to be rare, with the rate of converting to an open or laparoscopic procedure very low.