Robotic Surgery
Consultant Oncosurgeon, HIPEC and Robotic Surgeon
Traditional open method of surgery with long incision and scar was improvised with introduction of laparoscopic surgeries with minimal invasion and better outcome. More research in this field of minimal invasive surgery gave birth to Robotic surgery which is more precise, has minimal scarring, faster healing, lesser hospital stay and much reduced risk of infections.
The introduction of Robotic surgery has given new direction to minimal invasive surgery (MIS). The motive of this technology is to minimize tissue trauma usually associated with open surgeries and to be more precise while dealing with delicate organs during surgery.
Robotic surgery has been around for quite some time. The history of robotics begins with the world’s first surgical robot named “Arthobot” which was used for the first time in Vancouver, BC, Canada in 1983.
The PUMA 560 which was introduced in 1985 for CT guided brain biopsy. After 3 years , Davis et al performed resection of prostate using the PUMA 560, which eventually led to development of PROBOT- a robot designed for transurethral resection of prostate. In 1992, Integrated surgical supplies Ltd. of Sacramento, CA developed ROBODOC – a robotic system designed to machine femur with greater precision in hip replacement surgeries. ROBODOC was the first surgical robot to be approved by the FDA.
The further development in robotic systems was carried out by Intuitive Surgical with the introduction of da Vinci Surgical System and Computer Motion with ZEUS and AESOP robotic surgical system. Intuitive Surgical bought Computer Motion in 2003; ZEUS is no longer marketed.
What is Da Vinci Robotic System?
In this technology, a surgeon sits at the console and operates by managing robotic arms. The da Vinci System
represents the latest of the surgical and robotic technology. It translates the surgeon’s hand movement with precision
for instruments of the surgical arm to reach inside the body for finer and accurate procedures giving better results. The
3D high definition vision system and wide range of movement helps surgeons to do procedures with more efficacy and
better outcomes.
This Advanced Technology Consist of Four Main Components
Surgeon Console
It is a few feet away from the patient operating table. The surgeon sits in the console and views the surgical field with 3-D magnified vision system and performs the procedure by controlling surgical arms . This system can also improve depth perception, giving surgeons 3-dimensional view compared to 2-dimensional vision they usually get with normal endoscopic procedure. The surgical fields are magnified 10 times for greater surgical precision.
The surgeon console makes the surgeon experience immersive and interactive, making the procedure safer for the patient.
Patient Side Cart
It consists of a robotic arm which is in direct contact with the patient. It has two or three instrument arms and one endoscope arm. One of the greatest advantages of this system is that the camera and all the Robotic arms are directly in control of the surgeon through the Surgeon Console. The reliance of the surgeon on his assistants decreases and the precision of the surgery increases.
Endowrist Instruments
These detachable instruments help Robotic arms to maneuver in different ways so as to simulate fine human movements. The seven degree of movements means that the Robotic instruments can provide considerable choice in rotation and pivoting of surgical instruments, even greater than the natural human wrist!
Tremor filtration ensures that the natural tremors of the surgeon's hands, which are magnified in Laparoscopic surgery are completely eliminated in Robotic surgery, ensuring greater precision and safety.
Motion scaling ensures that the movements of the surgeons hands at the Surgeon console are converted into precise finer movements at the instrument tips, again adding to precision and safety
3-D VISION SYSTEM
The camera unit or endoscope arm provides enhanced 3 dimensional images. This high resolution images allows surgeons to have better vision and safety compared to conventional or laparoscopic surgery.
Advantages of Da Vinci Robotic System
- This system improves depth perception, giving surgeons a three dimensional view compared to two-dimensional vision they usually get with normal endoscopic procedure.
- The surgical fields are magnified 10 times for greater surgical precision. This is especially important when precise surgical steps need to be performed in a confined space with limited margin for error, like surgery in the pelvis.
- There is tremor filtration so that the natural tremors which are magnified in laparoscopy are completely eliminated in Robotics
- Robotics provides motions scaling which means surgeon’s gross hand movement can be reduced to finer movements providing accuracy in tight spaces while operating
Advantages Patients Includes
- Hospital stay is significantly reduced in almost all surgeries performed robotically
- Less pain and quicker recovery – the remote centre technology ensures that even the robotic arm movements are minimum at the level of the abdominal wall and only the endowrists are used for most of the dissection. This significantly minimizes tissue trauma and ensures lesser pain, infection and early recovery.
- Better Surgical scar.
- Reduced infection rate.
- Early recovery period
Disadvantage Presentation
Requires highly trained
Dr. Sanket Mehta has been trained in performing Robotic Cancer surgery at Seoul (South Korea) and Montpellier (France). Dr. Sanket performs colorectal cancer surgery using the Da Vinci Robotic system at Saifee Hospital on a weekly basis. He has performed several other surgeries using the robotic system, like Radical hysterectomy, radical esophagectomy, distal pancreatectomy and retroperitoneal lymph node dissection. He has devised his own unique techniques of docking the robot to ensure optimum utilisation of the robotic system and minimised operative time.
High device cost
With this technology, surgery for a number of cancers like pancreatic cancers, colorectal tumors, uterine tumors; stomach and esophageal tumors can be performed with better results. The patients recover faster; have lesser blood loss and reduced hospitalisation as compared to the traditional method of surgery. The rate of infection in robotic surgery is much lesser compared to traditional surgery. Most importantly, combined with the skill and knowledge of a trained and experienced surgeon, Robotic surgery offers a unique level of safety that is unparalleled. Patients can talk to their doctor to decide whether da Vinci surgery is suitable for their condition or not.Influence Procedures
Rectal Cancer Surgery
Treatment of rectal cancer has been an ever-evolving field with institution of multi-modality treatment which has led to better survival, better quality of life and better sphincter-preservation rate in these challenging tumours. A significant proportion of patients now go for neo-adjuvant radiotherapy or chemo-radiotherapy prior to surgery, which leads to higher rate of sphincter-preservation (avoiding a permanent stoma) with a lower local recurrence rate.
This translates into better quality of life for the patient. However, these are complex procedures with a long learning curve, especially by the Laparoscopic approach. Studies have shown that the average learning curve is more than 75-150 cases for such procedures.
The disadvantages of Laparoscopic surgery like Camera operator reliability, counter-intuitive movements, poor ergonomics, 2 D vision, exaggerated tremors and involuntary movements, mono-axial movements and pivoting of the instruments are responsible for this long learning curve. These disadvantages are addressed by the advanced Da Vinci Robotic system. In the Da Vinci System, the Camera has 10 times the magnification and is completely under the control of the surgeon. The surgeon console offers a completely immersive and interactive 3 D vision system
which offers an unparalleled vision, remarkably better than Laparoscopic or Open surgery. The instruments are jointed and the Endowrist technology offers 7 degrees of freedom and 90 degrees of articulation making the instruments more versatile than the human wrist as well. The motion scaling and tremor filtration ensure that there are no involuntary movements and the movements of the surgeon on the console are replicated into precise movements inside the body. These features are extremely useful while performing Total Mesorectal Excision (TME) for rectal cancer.
Studies have shown that the negative impact of Body mass index (obesity) and male pelvis on the completion and complication rates in Laparoscopic surgery for rectal cancer, is eliminated by the Da Vinci Robotic system.
Colon Cancer Surgery
Colon cancer incidence in India is on the rise and is increasingly being diagnosed in the early stages due to increasing awareness.
The Da Vinci Robotic system is particularly useful in performing left sided colon resections with an increased margin of safety and precision. In the hands of an accomplished Laparoscopic surgeon, the switch over to the Da Vinci system takes no time and the advantages of the Da Vinci system like the 3 D vision, the Endowrist technology and tremor filtration ensure that the patients get the best quality care. For right sided colon cancers, the Da Vinci system may offer a unique opportunity to perform a completely intra-corporeal anastomosis with a greater margin of safety.
Endometrial Cancer Surgery
Endometrial cancer incidence is on the rise with increasing obesity. The surgery for endometrial cancer may involve just a total hysterectomy, or it may involve a total hysterectomy with dissection of all the lymph nodes in the pelvis and retroperitoneum (lymph nodes along the major blood vessels).
Surgeons dealing with these tumours must be adept to perform these procedures and change the operative plan based on intra-operative findings. The traditional open surgery usually involves a long abdominal incision and a prolonged hospital recovery period, apart from the pain and need for antibiotics. Obesity and diabetes increases the risk of infection. This is of particular importance in these patients since these cancers generally occur in this subset of population.
Minimal Invasive surgery, in particular Robotic surgery with it’s 3 D vision and Endowrist technology, is ideally suited for this malignancy since it dramatically increases the efficiency and safety of the procedure, helps in dissection in the confines of the pelvis, and negates the potential difficulty and morbidity added by obesity. Unlike traditional open surgery which involves a long duration hospital stay and potential for infection, most Da Vinci Robotic Endometrial cancer surgery patients go home within 48 hours of surgery.
Cervical Cancer Surgery
Cervical cancer is the commonest cancer of the female genital tract in India. When diagnosed in the early stage, surgery itself is potentially curative. However, the traditional method of surgery involves a big abdominal incision and a long recovery period. Since the dissection involves a complex dissection of the parametrium (ligaments of the uterus) and the ureter and the pelvic nerves deep in the pelvis, Minimal invasive surgery, in particular the Da Vinci Robotic surgery offers a unique advantage because of its 3 D vision, 10x magnification and the Endowrist technology.
There is very little blood loss, negligible risk of infection and excellent visualization of structures like the pelvic nerves and ureter leading to a safe surgery. Obesity does not affect outcomes in the hands of an experienced Da Vinci cancer surgeon. Unlike traditional open surgery which involves a long duration hospital stay and potential for infection, most Da Vinci Robotic Endometrial cancer surgery patients go home within 48 hours of surgery.
Oesophageal Cancer Surgery
Oesophageal cancer poses a unique challenge because of its anatomical location. Tumours of the mid and lower third of the oesophagus which are loco-regionally confined can potentially be offered curative treatment with surgery, often after some chemotherapy or chemo-radiotherapy.
Traditional surgery usually involves a large thoracotomy (opening the chest wall to gain access to the oesophagus) which entails a significant risk for pulmonary complications, morbidity and pain. The advent of Minimal Access surgery changed this scenario with several studies proving that Video-assisted Thoracoscopic (VATS) oesophagectomy is oncologically equivalent to traditional open surgery. However, VATS esophagectomy has a steep learning curve and due to monoaxial movements of laparoscopic instruments, has certain limitations in difficult cases.
The Da Vinci Robotic surgery is particularly suited to this situation. With the 10 X zoom, the vision quality is unmatched. The Endowrist technology gives unmatched dexterity and range of movements that makes dissection in difficult to access regions within the thorax and mediastinum easier and safer. Studies have shown that the blood loss and pulmonary complications are lower and hospitalisation is shorter when esophageal surgery is performed by the Da Vinci Robotic system. Another significant advantage over traditional surgery is the remarkably lower pain by the Robotic technique.