A Primer: Robotics in Surgery

Robotic surgery, more accurately but less frequently termed computer-assisted surgery, is in its infancy, but it is beginning to demonstrate some benefits for patients, surgeons and hospitals. In an ideal application, robotically-assisted surgery allows for greater precision with less trauma and a faster recovery for the patient.

Surgeons at nearly 200 U.S. hospitals are attempting to determine the utility of robotic surgery with Intuitive Surgical's da Vinci robot, the only robot currently approved by the FDA. Since it gained FDA approval three years ago, surgeons across the country have been exploring procedures with the robot and attempting to define appropriate applications.


THE CLINICAL PICTURE

Robotics represents an entirely different way of doing surgery. At the same time, however, the robot is a surgical tool - not a surgeon. The robot and its instruments, rather than the surgeon, are adjacent to the patient. The surgeon sits at a console connected to the robot, where he views images and directs the procedure. The system translates movements of the surgeon's hands, wrists and fingers into real-time movement of surgical instruments.

Mark Granson, MD, chief of surgery at St. Luke's Hospital and Health Network (Bethlehem, Pa.), has been using the da Vinci robot for nearly three years and has completed a variety of surgeries with the robot, including lung resections, prostatectomies, gall bladder removals, adrenallectomies and gastric reflux and gynecological surgeries. He explains the benefits. "With the robot, we have an almost 3D view vs. a conventional laparoscopic 2D view. In addition to better imaging, we have a better ability to dissect because the robot functions with an articulated hand."

On the imaging side, the robot incorporates a 3D endoscope and image processing equipment for 3D images of the surgical field. The articulated wrist is a substantial improvement over the human hand as it provides 360-degree maneuverability. The combination often translates into smaller incisions; some procedures that require a four- to five-inch incision with conventional surgery can be completed with a less than one-inch incision with the robot.

While robots have been put to work in a variety of procedures, surgeons agree that their use should be limited to procedures where their use translates into benefits. Robert Ashton, MD, director of minimally invasive and robotic thoracic surgery at St. Luke's-Roosevelt Hospital Center in New York City, explains, "There are no absolutes for the robot. Sometimes, we use it for the whole surgery and sometimes we use it for just a part of the surgery." 

At St. Luke's Bethlehem, two primary uses are prostate and lung resections. Granson says robotically-assisted prostate resections result in less blood loss and less nerve loss than open surgery. This could correlate with better outcomes, shorter lengths of stay and reduced costs. Another procedure where the robot outperforms conventional surgery is a sternotomy. "The difference is night and day," confirms Ashton. Instead of a large 12-inch incision to open the chest, a robotically-assisted sternotomy consists of three small incisions with recovery time in the one to two week range vs. two months for the more invasive, conventional surgery.

Even when outcomes aren't improved, the robot may be the better option because it enables greater precision. Take a myotomy to cut the esophageal muscle and normalize swallowing for patients with achalasia. The conventional technique relies on a thoracotomy or laparoscopic. Ashton explains, "The robot allows us to be even more precise than we could laparoscopically."

Paul Curcillo, MD, vice chairman of surgery and director of robotics and minimally invasive surgery at Drexel University in Philadelphia, has been using the da Vinci robot since October 2002. He says, "The primary clinical benefit is that it lets us offer better minimally invasive surgeries." Today, surgeons at Drexel primarily deploy the robot in abdominal surgeries-urologic, kidney and prostate procedures-such as adrenallectomies and tumor debulkings. Although Curcillo and his colleagues started out using the robot for all types of procedures, the team has backed off and is using the robot where it makes most sense clinically. He explains, "We don't do gall bladders with the robot anymore. It costs more and takes more time with the robot. This is an example of a procedure that we can do quickly and easily with a laparoscope."


SUPPORTING THE ROBOT

What does it take to implement robotic surgery? St. Luke's Ashton explains, "Additional imaging and IT infrastructure isn't necessary with the robot. Hospitals need the robotic device, the clinical skills to use the robot and a dedicated team to work with the robot." The prerequisite clinical skills include a thorough understanding of minimally invasive surgical techniques.

Granson admits, "There is a definite learning curve with the robot." Intuitive Surgical provides training with 10 cases, which gets sites up and running. Then hospitals typically continue with internal training and workflow changes as they deploy the robot. Curcillo describes the robot as a "2,000 pound gorilla." Because it is quite a bit larger than a surgeon, it takes over the field and requires adjustments on the part of the surgical team. For example, anesthesiologists are located farther away from the patients during surgery. And nurses need to learn about set up of the robot, cleaning the robot and handling its instruments. St. Luke's-Roosevelt introduces new clinical staff to the robot one at a time, with Ashton or the director of robotics present as new surgeons perform surgery with the robot.


THE FUTURE OF ROBOTICS

The future will undoubtedly bring additional clinical benefits to the table. For example, cardiac procedures may be the next frontier in robotic surgery. Researchers at St. Luke's-Roosevelt, for example, are studying epicardial lead placement for biventricular pacing for patients with congestive heart failure. Conventional placement procedures are less than 100 percent effective, says Ashton, and the robot may be able to better spot and place the lead. Mitral valve repair is another cardiac procedure that may be better performed with the robot. There are other up and coming applications as well. "Robotic applications in urology are going to grow," predicts Curcillo. Colon resections are probable, adds Granson.

While the clinical work continues, surgeons agree that technical work also is critical. Ashton notes, "This is just the beginning of robotics. The technology is exploding with a lot coming down the pipeline."

Ashton believes competition, i.e. a second vendor, will improve quality. E. Carmack Holmes, professor and chairman of the University of California Los Angeles department of surgery, agrees. "This is a first-generation technology that needs a lot of research and development," he says. A smaller, more mobile platform is essential, says Holmes.

Curcillo says the maturation phase should include additional instruments. Although general surgeons have 3,000 tools at their disposal, and laparoscopic surgeons have some 500 instruments, robotic surgery is limited to fewer than 20 instruments.

Another way to improve on the technology is to improve surgical skills. Researchers at UCLA are trying to develop a Haptic feedback system to help surgeons feel and see what they are doing during robotically-assisted procedures. Holmes continues, "We'd like to integrate the da Vinci device with x-ray, 3D imaging and ultrasound to create an augmented reality to allow surgeons to see through organs. If we can fuse all of these devices, we may eventually be able to do surgeries that aren't possible now."


CONCLUSION

Robotically-assisted surgery is a promising new field with the potential for benefits in terms of improved clinical outcomes, shorter hospital stays and reduced costs. These benefits are not even across procedures, and hospitals need to understand which procedures best fit the robotic profile. This list, however, will likely be somewhat fluid as conditions can vary on a case-by-case basis. The technology remains in its infancy; significant research on both the clinical and development fronts needs to happen to more fully understand and realize the potential of robotically-assisted surgery.