Robotic-assisted visceral surgery: Where is it?

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Reference

Robotic-assisted visceral surgery: Where is it?

HAGEN, Monika, et al.

HAGEN, Monika, et al . Robotic-assisted visceral surgery: Where is it? Swiss Knife , 2008, no.

4, p. 12-15

Available at:

http://archive-ouverte.unige.ch/unige:34454

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1

Education 1

Robotic-assisted Visceral Surgery: Where is it?

The robot overcomes the technical limitations of laparoscopy by restoring the teel of open surgery in a minimal invasive environment.

Monika E. Hagen, monika.hagenrclhcuge.ch Oliver J. Wagner, olli.j.wagnerfilgmail.com Stephan A. Vorburger, stephan.vorburgerfilinsel.ch Daniel Candlnas, daniel.candinasfilinsel.ch Philippe Morel, philippe.morelrclhcuge.ch

Withln the past decades, modem surgery has anticipated the concepts of evidence-based medicine. Also, within this development, initial post­

operative course and pain has been adopted as important factors of the surgical olltcome. Minimal invasive surgery demonstrated Jts su­

periority concerning the earty postoperative course when compared to traditional open surgery'·3. Still, minimal invasive surgery has not been overwhelmingly adopted and remains the less used method especially for aclvanced surgery in the US and Europe in ail surgical fields'-"! But why has the majority of surgeons not yet incorporated this patient-wise advantageous method of laparoscopy when evidence-based medicine support their use?

Laparoscopy is diffitult to learn and to perform" Novices to the lield 01 mi­

nimal invasive surgery face a significant learning CUNeo Many advanced procedures eontain a level 01 difficulty even beyond the possibilities 01 tra­

ditional laparoscopie surgery mainly beeause of the teehnical limitations of laparoseopy: Two-dimensional imaging leads to impaired depth perception and disorientation. Laparoscopie rigid instrumentation offers a limited range of motion and lewer degrees of freedom when eompared ta the surgeon's hand. Fixed troears act as a lulcrum and lead to motion reversai and motion seallng of tfle tip of the laparoscopie instrument. Due to the length of lapa­

roscopie instruments, the surgeon's resting tremor 1s enhanced. Frequently, the surgeon is l'orced to perform in an uneomfortable and ineffieient position and instruments, monitors and surgeon are misaligned.

But how can we overcome these technicallimitations to provide secure mini­

mal invasive surgery to benelit the patient's outcome? The solution has been deveioped over the past decades: Robotie surgery""!

History of rebotie surgery

Development of Robotie surgery started in the late 70ies and early SOies and was mainly driven by two US institutions: The army and the NASA. The original motivator was to perform tele-surgery on patients in remote places such as a baltle-field or the outer spaee. Both projects were more or less equally sueeessfui and lead ta the developmenl of Iwo different robolie systems: the da Vinci~Surgical System (US army in cooperation with the Stanford Research Institute) and the Zeus robot (NASA). 80th projects were commercialized, the da Vinci Surgieal System by Intuitive and the Zeus ro­

bol by Computer Motion. and received the FDA approval for laparoscopie abdominal surgery in the years 2000 and 2001, respectively. Even before

FDA approval, a lirst robotie choleeysteetomy was pertormed on a patient in Beigium with "Mona", the preliminary version of the da Vinci~ Surgieal Sys­

tem'. Another landmark in robotie surgery was the operation Lindbergh in 2001: The first trans-atlantic cholecystectomy took place with the surgeon operating in New York and the patient being treated in Strasbourg, France'"' This surgical event never reeeived the deserved atte[1tion mainly because of the tragie events of 9/11 that happened only a few days after.

ln the year 2003, Intuitive bought the company Computer Motion and set an end to the Zeus robot: Ali intellectual property was ineorporated and products 01 Computer Motion were no longer available on the market. Since then ail robotic surgeons lace the unlavourable situation of Intuitives indefeasible monopole with ail its strategie effects such as outrageous pricing. But exaetly because 01 th1s monopole, the da Vinci~ Surgical System was blessed with growing figures in sales and further developments. Until now, more than 650 surgical systems are in clinieal use worldwide and new features are develo­

ped on a regular base. The latest technical innovation is the integration of a high definition visualization system whiell is already commercially available, The Robotic system (daVinci"')

The da Vinci" Surgical System was specilically designed ta address the technieallimitations of conventionallaparoscopic surgery: The robot delivers a high-quality, magnified, surgeon-eontrolled 3-dimensional, stable image, eontains of instruments that allow intuitive control with tremor reduction.

motion scaling and wristed movements,,8 The robot contains 4 major ele­

ments: The surgeon's console, the surgieal patient-side cart, EndoWrist'"

instruments and the laparoscopie tower. The surgeon's console is the work

J

Picture 1: The da Vincf' Surglcal Console

Picture 2:

The da Vinc!" Insite Vision System fmd Jay-sticks

Plcture4:

The da Vinci® SurgicaJ Cart

space ot the surgeon (picture 1). It contains the binocular viewers of the In­

site Vision System (picture 2), joy-stick-like instrument controliers (picture 2) and foot-paddles for steering the camera and coagulation devices. On top of this. the console allows the surgeon to control the setup and it is embedding both. the computers hard- and software. Due to two three-chip cameras and two oplical channels creating two images as weil as sophisticated image processing equipment. the Insite'" Vision System offers a spectacular high­

resolulion true-to-lile 3-D image (picture 2 and 3). Two light sources optimize the Ilght intensity and the surgeon himself can control focus and position 01 the camera. Otherwise, the surgeon is sitting comfortable in an ergono­

mically optimal and comfortable position, controlllng the instruments with his fingers in the master controls Goy-sticks) below the display whiie having elbows resting on a padded bar and the lorehead against a pad above the vision system. Approximation of thumb and index (or middle finger) operates the jawed instruments in a completely intuitive lashion, nle transmission of surgical commands from the surgical console to the surgical cart is accom­

plished by multiple wires.

Pîcwre 3: The da Vinc!" 30 and 0 degree endoscopes with 2 cameras

The surgeon's cart provides either three or four mechanical arms (picture 4).

The endoscope arm holds the camera and further instrument arms execute the surgeon's commands, The arms carry a series of multiple positioning joints which provide the excellent range of motion during surgery. A full range of different surgical EndoWrist^œl instruments are available including energetic instrumentation such as the Harmonie Ace or the Gyrus forceps (picture 5 and 6). Those instruments can be changed very rapidly by the patienl-side assistance without influenclng the position 01 the robotic arms. Ail instru­

ments except the Harmonie Ace (Ultrasound technically cannot flow ar<2und corners) offer six degrees of freedom at the tip plus the seventh degree by the action of the instruments itself. Ali instruments are semi-disposable and can be sterilized between 10 and 20 times.

"

What makes da Vinci special?

The laparoscopie tower incorporates ail features of a standard endoscopic stack such as assistant's monitor, insufflators. high-intensity illuminators and a camera unit. For better conversation between the surgeon and his team, the laparoscopie tower is furthermore equipped with both speakers and a microphone, Ali in ail. lhrough the specific "da Vinci"'"-characterislics of 3-D vision, motion scaling. tremor filtration, ambidexterity, hand-eye-alignment and improved ergonomies. the robot overcomes the technical limitations of laparoscopy by restoring the "Ieel" of open surgery in a minimal invasive environment.

Therefore. robotic surgery is the most beneficial in procedures that are very ditficult or even not suitable to perlorm with the instruments of conventio­

nallaparoscopy. In the field al Urology, robolies already induced a dramatic change: Traditionally by open sUrgery perlormed radical prostatectomy is now more and more accomplished with the robot. Many studies suggest that robotic prostatectomy may offer enhanced cancer control and lower incidence of impotence and urinary incontinence when compared ta bath open and conventional laparoscopic prostatectomy, These improved clinical outcomes in combination ""ith strategie marketing activities have established robotic prostatectomy as a frequently desired approach by patients and dra­

ve ta growing markets for robotie urologjsts, Especially in the US. traditional urologists without robotic experience are facing more and more a dramatic loss of patients.

Role of robotic-assisted surgery in visceral surgery

Unlike in Urology. an advantage of robotic-assisted surgery in the GHract over laparoscopie or "open" surgery has yet to be shawn, Despite an in­

creasing amount of literature about robotics in visceral surgery ooly few studies offer valu able data. Case-reports account for most of the literature.

They indicete. thal. robotic-assisted surgery is basically feasible for oearly ail intra-abdominal procedures"'''. In view ot the enhanced dexterity and the improved vision of the deviee compared ta laparoscopy, this is not surpri­

sing. The adaptation of the robotic system for interventions (hat have only been possibie with the open technique, are sometimes stunning and even daring. Hemihepatectomies. pancreatic resection including Whipple-Opera­

tians, gastrectomies for malignancy and oesophagus-resections have been reported 11 ,",10,

Education 1

Most of the robotic visceral surgery literature deals with robotic cholecystec' tomy. Prospective randomized trials report longer OR-times, due 10 instal·

lation of the robot and increased costs compared to the laparoscopie ap­

proach⁹. 1BIl. The same has been found for robotic fundoplication (Nissen) and robotic splenectomy"18.19. Clinically, both procedures result in compa­

rable outcomes. Newer reports found improved OR-times in fundoplication and rectal resections. Ali of the findings. however. are limited to the outcomes studied; it is, for example, not yet evidenced if robotic surgery could improve postoperalive pain, postoperative recovery or wound infection.

Our experience in Geneva and Bern

Our initial experience in Geneva and Bem is similar to the described litera­

ture. The extended OR-times are mainly due to a rather complex setting-up and docking of the robot, both can be significantly reduced with increasing routine, not only of the surgeons ln charge but more importantly 01 the OR­

team. In rather easy Interventions with short OR-lime, the 10ss of time due ta the above mentioned factors cannot be overcome by a facilitated, hence, faster preparation. Evaiuation of our first 50 procedures revealed a median robotic docking lime of merely ten minutes,

an

Why then, should robotic surgery be performed for procedures that are lapa­

roscopically easy to do (other than the, admittedly, thrill of handling a novel, 2Mio CHF gadget that looks cool)? (Alter ail, we are surgeons...) - Despite belng tagged "Intuitive" by name, robotlc surgery has to be learned and standardized, simple and frequent procedures are excellent training ground for Ihe whole robotlc team. The emphasis here is on "team". meaning that

"Lagerungspfleger, technische Op-Assistenten, Anasthesisten, Assistenlen und Operateur", ail h.ave to adapt to this new approach. Cholecystectomy and fundoplications are a great help in getting started with robotic surgery.

However, our mutual experience in Geneva and Bern is that whereas chole­

cystectomies are, Indeed, weil standardîzed and frequent, "easy" migi1t not completely reflect reality. A cholecystectomy, ln our opinion, is one of a few procedures, that are actually harder to do with the robot than laparoscopical­

Iy. This is due to the faet that many steps of the preparation are easier and laster done with true tactile feed-back (this is especially true in the presence of inflammation).

What are we training for?

If simple laparoscopie interventions only serve as training, one question still remains: "what are we training for"? Where wou Id robotic surgery be reasonable to do? We have little doubt that the more complex and diHicult to access an intervention is, Ille better will robotic surgery pertorm against other means of surgery. limitations are the extent of the OR field due to the

limited range of motion of the robot (with the new DaVinci S system, this range has greatly improved) and the higher magnification (10x vs. 4x with standard laparoscope). Hence, the oesophagus. upper gastric region. pelvis and retroperitoneum are operation sites where the robotic system can exce!.

Our experience with robotic assisted transhiatal oesophagectomy on cada­

vers showed lhat preparation under direct vision and collection of Iympha­

tic nodes up to the height of the jugulum could be performed. Accordingly, first reports on robolic assisted transhiatal oesophagectomy are enthusias­

tic about this possibility. In rectal cancer, 2-4 years experience wilh several hundred participants showed the ease of the preparation of the lower rectum compared to laparoscopy20..2,. - Nowadays. the robotic system is increasingly utilized in an area. where laparoscopie surgery has previously shown con­

siderable advantages over open surgery: bariatric surgery. Despite being a procedure that involves almost the whole abdominal cavity (which is not very hard to access) robotic surgery adds to laparoscopie gastric bypass the pos­

sibility to sew intracorporally. First studies about robotic gastric bypass frf;lm 2005 reported tewer complications related to the anastomoses (Ieakage and stricture) and a reduction in OR time''''-''. Further data followed, confirming the initial experience of the Stanford group23·~5. Since we have introduced the da Vinci Surgical System into the Geneva bariatric programme in summer 2006, we are closing in on the 45^th patient and we have observed no compli­

cations regarding the anastomoses. We learned that tlle quality of robotically sewn anastomoses regarding the rate of leakage and stricture is superior to stapled anastomoses ill conventionally laparoscopie gastric bypass.

From the currently available data. that show similar clinical outcome alter laparoscopie or robotic interventions, one could deduce, that the relatively novel approach of robotic surgery has a) a very steep learning curve (is easier to pertorm) compared to laparoscopy and/or b) will have a clinically better outcome in time, compared to laparoscopic procedure, whlch developed over the last 18 years to the levels of today. In other words could we com­

pare laparoscopic results from the first hours to the results achieved with the robot today. the advantage of the latter would be obvious. The assumption that robolic surgery will ultimately become favourable over laparoscopy in more complex procedures. is, however. only correct, if the current robots will be continuously improved.

Lessons leamed

With ail the praise from the last paragraph, wi1y is not everybody doing ro­

botic surgery? Alter ail, nor Geneva nor Bern have been at the forefront of robotic surgery. Why were robots bought, used, put ln the storage room and then forgotten (we are talking about visceral surgery here. Urologist and gy­

naecologist have qulckly learned to integrate the additional opportunities of robotic surgery in their daily business). - The Iwo main reasons olten were miscommunication and lack of focus. Even if a surgical director realized the potential of robotic surgery. the patience and dedicatlon to reach the exper­

tise of positioning Ille robot and performing operations where it could make a difference was minimal and enthusiasm was quiekly replaced by scepti­

cism, More oflen robots in visceral surgery were doomed due to the lack of communication: OR team members and colleagues alike did not realize that, in order to acquire the skills above menlioned, the robot had to be introdu­

ced in standardized, simple and frequent operations. This initial phase led to the perception, Ihat robotic surgery is a costly, time-consuming gadget that yields at best the same results as th~ fast and simple laparoscopy. Subse­

quently, the robot-assisted operations were limited to times when the OR was not used. The resulting low frequency of lhese operations did not allow the OR personal to familiarize wlth the equipment, hence. robotic set-up per­

sistently used very much time. amplifying the negative perception.

We experienced, that once it has been clearly communicated to ail OR per­

sona!, that there will be a longish initial phase, during which time and money has to be invested ta reach the next level and that, ultimately, robolic sur­

gery will be useful for more complex interventions, criticai voices diminis- Picture 5: The 5 mm da Vinct'> Instruments

swlss Ilnite 2008, 4

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Future of robotic surgery

Still. missing data is generally a great problem of robotics in digestive surge­

ry. We have promising preliminary results fTom feasibility studies, but we lack of further scientific evidence as available in urology lor radical prostatecto­

rny. Main reason lor this is that only lew digestive centres operate with the system. Furtherrnore. many digestive procedures are not as standardized as a radical prostatectomy which makes multicenter randomization an extreme­

Iy diflicult undertaking, if not even impossible. Another concern is the large number of patients needed for a properly powered prospective, randomized trial comparing robotic versus laparoscopie procedures. Ali in ail, satisfying outcomes are nearly irnpossible ta create at this point.

Bul. il data is not perfectly convincing and the da Vinci~ Surgical System sa rnassively expensive. why should we bother working with the robot? Where is our benefit? Let's change the point of view: The robot is not just the overp­

riced. lime-consuming toy that brings no actual benefit ta the clinic; the robot is our future by resembling an information system with arms. Mid and long term, we will be able to integrate ail surgical functions into our information system "robot"26.2^7• We will be able to superimpose scans and x-rays onto the References

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roscopie robolics that are heid by one company causing the massive oosts 01 robolic surgery. Imagine that surgical robots sooner or later will be affordabie for everybody. We will easy be able ta create enough scientific data and the progress will go ahead! We can either invest in this revolutionary technology or watch the others laking over the lead! Sa, let's go for the future!

Pic/ure 6: Examples of 8 mm da Vine'- Instruments

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