Wednesday 30 April 2014

What is Robotic Surgery by Dr. Arun Prasad. Senior Consultant Surgeon - Minimal Access Surgery, Apollo Hospital. (Disclaimer: Hospital Guide Foundation provides a neutral platform for Patients/attendants & Doctors to express their opinions/experiences. These views are of the writer.)

Robotic surgery, computer-assisted surgery, and robotically-assisted surgery describe the technological developments that use electro mechanical systems to help a surgeon perform surgery.
The davincirobot which is currently the market leader is not Mr. Data from Star Trek performing precise surgery on the human body.
The general term "robotic surgery" is used to refer to the technology, but it is easy for people to get the impression that the robot is performing the surgery. Actually, the current Robotic Surgical System cannot run on its own. This is due to the fact it was not designed as an autonomous system and lacks decision making software. Instead it relies on a human operator for all input.
All functions- including vision and motor functions— are performed through remote human-computer interaction. The current system is designed merely to replicate seamlessly the movement of the surgeon's hands with the tips of micro-instruments, not to make decisions or move without the surgeon’s direct input.
In other words it is like a PS3 or an Xbox where you control the movements completely and hence the outcome of the ‘game’.
Robotically-assisted surgery was developed to overcome both the limitations of minimally invasive surgery or to enhance the capabilities of surgeons performing open surgery.
In 1985 a robot, the PUMA 560, was used to place a needle for a brain biopsy using CT guidance. In 1988, the PROBOT, developed at Imperial College London, was used to perform prostatic surgery. The ROBODOC from Integrated Surgical Systems was introduced in 1992 to mill out precise fittings in the femur for hip replacement. Further development of robotic systems was carried out by Intuitive Surgical with the introduction of the da Vinci Surgical System.
According to the manufacturer, the da Vinci System is called "da Vinci" in part "because Leonardo da Vinci invented the first robot", and also because he used anatomical accuracy and three-dimensional details to bring his works to life.
The system consists of a surgeon’s console that is typically in the same room as the patient and a patient-side cart with four interactive robotic arms controlled from the console. Three of the arms are for tools that hold objects, act as a scalpel, scissors, bovie, or unipolar or bipolar electrocautery instruments. The fourth arm is for an endoscopic camera with two lenses that gives the surgeon full stereoscopic vision from the console.
The surgeon sits at the console and looks through two eye holes at a 3-D and HD image of the procedure, meanwhile maneuvering the arms with two foot pedals and two hand controllers.

It scales, filters and translates the surgeon's hand movements into more precise micro-movements of the instruments, which operate through small incisions in the body.
To perform a procedure, the surgeon uses the console’s master controls to maneuver the patient-side cart’s robotic arms (depending on the model), which secures the instruments and a high-resolution endoscopic camera.
The instruments’ jointed-wrist design exceeds the natural range of motion of the human hand; motion scaling and tremor reduction further interpret and refine the surgeon’s hand movements.
There are multiple safety features designed to minimize opportunities for human error when compared with traditional approaches.
At no time is the surgical robot in control or autonomous; it operates on a "Master:Slave" relationship, the surgeon being the "Master" and the robot being the "Slave."
So the decisions on what to cut, where to cut, how to cut, when to cut, where to stitch, how to stitch etc are all taken by the surgeon and robot just replicates the hand movements.
This has been designed to improve upon conventional laparoscopy, in which the surgeon operates while standing, using hand-held, long-shafted instruments, which have no wrists. With conventional laparoscopy, the surgeon must look up and away from the instruments, to a nearby 2D video monitor to see an image of the target anatomy. The surgeon must also rely on his/her patient-side assistant to position the camera correctly. In contrast, the da Vinci System’s ergonomic design allows the surgeon to operate from a seated position at the console, with eyes and hands positioned in line with the instruments. To move the instruments or to reposition the camera, the surgeon simply moves his/her hands.
Some major advantages of robotic surgery are precision, miniaturization, smaller incisions, decreased blood loss, less pain, and quicker healing time. Further advantages are articulation beyond normal manipulation and three-dimensional magnification, resulting in improved ergonomics. Robotic techniques are also associated with reduced duration of hospital stays, blood loss, transfusions, and use of pain medication.
In addition, surgeons no longer have to stand throughout the surgery and do not tire 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.
By providing surgeons with superior visualization, enhanced dexterity, greater precision and ergonomic comfort, the da Vinci Surgical System makes it possible for more surgeons to perform minimally invasive procedures involving complex dissection or reconstruction.
However there are some downsides too. Surgical procedures performed with the robot take longer than traditional ones. Critics say that hospitals have a hard time recovering the cost ( Robot costs 1 million dollars to set up and a recurring cost of about 1500 dollars per surgery ).
A Medicare study found that some procedures that have traditionally been performed with large incisions can be converted to "minimally invasive" endoscopic procedures with the use of the Robot, shortening length-of-stay in the hospital and reducing recovery times. But because of the hefty cost of the robotic system it is not clear that it is cost-effective for hospitals and physicians despite any benefits to patients since there is no additional reimbursement paid by the government or insurance companies when the system is used.
Robotic Surgery has been successfully used in the following procedures:
General and Gastrointestinal Surgery: Cholecystectomy, Hernia repair,Appendicectomy, Nissenfundoplication for hiatus hernia, Heller myotomy for achalasiacardia, gastric bypass, adrenalectomy, splenectomy, small intestinal surgery, colonic and rectal surgery etc.
Bariatric Surgery: Gastric bypass, gastric sleeve resection and gastric banding.
Thoracic Surgery: Thymectomy, mediastinal tumor, lung resections, esophageal surgery.
Urology: Radical prostatectomy, pyeloplasty, cystectomy, nephrectomy, ureteralreimplantation.
Gynaecology: Ovarian cyst, Hysterectomy, myomectomy and sacrocolpopexy.
Cardiac Surgery: Coronary artery bypass, Mitral valve repair, endoscopic atrialseptal defect closure.
Head and neck: Transoral resection of tumors of the upper aerodigestive tract (tonsil, tongue base, larynx), transaxillarythyroidectomy

The computer-enhanced technology and robotic precision ensure a level of surgical precision never before possible. The use of robotics is changing medicine dramatically. As the technology continues to advance and patients experience the benefits of robotic surgery, the demand for robotic procedures continues to increase.
Apollo Hospitals is taking a major step to bring the benefits of this technology to cancer patients in India.
Compared with traditional open surgery and standard laparoscopic surgery, patients treated with robotic cancer surgery benefit from more precise and accurate surgery of the concerned region in addition to decreased blood loss. This leads to less pain, fewer complications, shorter hospital stay and faster recovery.
The greater precision and maneuverability allow the surgeon to perform complex robotic cancer surgery procedures in areas that may be beyond the reach of traditional or standard laparoscopic surgery.
It appears now that this is an option restricted to few select hospitals in the world. No one knows what the future holds and this is best illustrated by the following statement by Professor Douglas Hartree, Cambridge mathematician in 1951:
“All the calculations that would ever be needed in this country will be done on the three digital computers which are being built — one in Cambridge, one in Teddington, and one in Manchester. No one else, would ever need machines of their own, or would be able to afford to buy them."


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