Current state of robotic surgery

December 17, 2017

Surgical robots have been envisioned to extend the capabilities of human surgeons beyond the limit of conventional laparoscopy. The history of robotics in surgery begins with the Puma 560, a robot used in 1985 to perform neurosurgical biopsies with greater precision. This system eventually led to the development of the PROBOT, a robot designed specifically for transurethral resection of the prostate.

 

Currently, the da Vinci robotic system, is the only commercially available robot in gynecology. It consists of three main components: the robotic cart, the vision cart, and the operating console.

 

Components of the da Vinci surgical system: (A) Surgical console, (B) Robotic cart, (C) Vision cart, (D) Three dimensional vision system with endoscope, (E) EndoWrist.

 

Four robotic arms are mounted on the robotic cart, which can be placed freely next to the patient. The robotic cart docked is connected to the operating console through a cable. The da Vinci surgical system is equipped with a 3-dimensional vision system, in which double endoscopes generate two images resulting in the perception of a 3D image. In addition, robotic arms with surgical instruments have three or four joints, which reproduce the range of motion and dexterity of the surgeon's hand. The surgeon sits at the surgical console and performs the surgery by manipulating the controller in it. The movement is translated from the surgeon's fingers to the tip of the surgical instruments. During this process, the physiologic tremor is eliminated by the robotic system. These instruments, including the 3-D vision system and the EndoWrist, allow the surgeon to conduct more precise surgical procedures during surgery.

 

The Da Vinci System set-up is originally made by the American company Intuitive Surgical. Some of the special features it offers are a magnified vision system that gives surgeons a 3D HD view inside the patient’s body, ergonomically designed console where the surgeon sits while operating, patient-side cart where the patient is positioned during surgery and wristed instruments that flex at a far greater angle than the human hand

 

These robotic systems enhance dexterity in several ways. The surgeon’s ability to manipulate instruments (and thus the tissues) is greatly enhanced by the instruments with increased degrees of freedom. These systems are designed so that the surgeons’ tremor can be compensated through appropriate hardware and software filters. In addition, these systems can scale movements, so that large movements of the control grips can be transformed into micro-motions inside the patient.

 

Another important advantage is the restoration of proper hand-eye coordination. These robotic systems eliminate the fulcrum effect, making instrument manipulation more intuitive. With the surgeon sitting at a remote, ergonomically designed workstation, current systems also eliminate the need to twist and turn in awkward positions to move the instruments and visualize the monitor like done in laparoscopy.

 

The 3-dimensional view with depth perception is a marked improvement over the conventional laparoscopic camera views. Also to one’s advantage is the surgeon’s ability to directly control a stable visual field with increased magnification and maneuverability. All of this creates images with increased resolution that, combined with the increased degrees of freedom and enhanced dexterity, greatly enhances the surgeon’s ability to identify and dissect anatomic structures as well as to construct microanastomoses.

 

But this technology has its limitations. The principal weak point is the high cost of robotic surgery, which prevents robotic surgery from spreading worldwide. The cost to install the da Vinci robotic platform ranges from $1,000,000 to $1,500,000 and a 10% annual maintenance fee is needed separately. Other disadvantages include the absence of tactile feedback of robotic arms, and the requirement of larger ports for robotic surgery compared to conventional laparoscopic staging surgery. Placement of a large sized port, more than 8-mm in diameter for robotic surgery, is larger than that of laparoscopic surgery, and causes aggravated postoperative pain and produce poor cosmetic results. Another disadvantage is the size of these systems. These systems have relatively large footprints and relatively cumbersome robotic arms. This is an important disadvantage in today’s already crowded-operating rooms. It may be difficult for both the surgical team and the robot to fit into the operating room. Some suggest that miniaturizing the robotic arms and instruments will address the problems associated with their current size. Others believe that larger operating suites with multiple booms and wall mountings will be needed to accommodate the extra space requirements of robotic surgical systems. Moreover, there is a lack of compatible instruments and equipment, which increases reliance on table-side assistants to perform parts of the surgery.

 

Nevertheless, the future of robotic surgery is nearly as promising as the human will to invent better ways of accomplishing delicate medical procedures. It is reasonable to assume that the current advantages of robotic surgery systems will be expanded upon in the next generation of medical robotics. The prospects are exciting; the future is surely in the hands of robots.

 

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