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[three_fourth_last]Milestones in medicine, such as vaccinations or antibiotics, can fundamentally transform many lives at once. Milestones in surgery can do so one life at a time. We are entering a new era in surgery where we can achieve just such a transformation. Robotic surgery, or minimally invasive surgery with the daVinci® Surgical System, affords us the precision and dexterity to perform complex operations through keyhole incisions once only accomplished with large open wounds. As a result, hospitalisations are shorter, costs are lower, and complications are fewer.
How does this technology differ from conventional minimally invasive techniques such as laparoscopy that have been around for decades? First of all, a binocular camera sends a 3-D, high definition live video feed to a viewing station through which the surgeon sees inside the patient. The surgeon maintains control of what he/she is seeing at all times, and can zoom in for a magnified view of small critical structures when necessary. In contrast, with conventional laparoscopy, an assistant manipulates a monocular camera by hand while the surgeon tries to communicate what he/she needs to see.
Second, the instruments are designed to move with six degrees of freedom – that is, like a human wrist. The surgeon manipulates the instruments through a computer interface while sitting at a console at the patient’s bedside. Conventional tools, also known as “straight stick” laparoscopy instruments, are manipulated by the surgeon’s hands from just outside the patient’s body. These instruments have only three degrees of freedom, resulting in much less mobility and precision. This is especially important during suturing, when turning the wrist directs the curve of the needle through tissue.
Finally, with robotic surgery, the surgeon sits at the console, performing the procedure from an ergonomically superior position resulting in less fatigue, shorter operating times, and greater operating room efficiency.
As an example, let’s look at the case of a 34-year old, massively obese, diabetic woman who spent three months recovering from her last surgery due to a wound infection with antibiotic-resistant staphylococcus aureus. Now she has enormous uterine fibroids causing hemorrhage and life-threatening anemia. Using this new surgical platform, we performed a hysterectomy through five 8mm incisions, and the patient left the hospital in less than 48 hours. Comparing robotic surgery and conventional surgical techniques with respect to cost and the patient’s quality of life, this is truly revolutionary.
In the realm of cancer treatment, the revolution is on. In the United States, the vast majority of surgeries for prostate cancer are now performed robotically. Studies suggest equivalent cure rates with shorter return to work and improved rates of return to sexual activity. In the past, early cervical cancer was treated with an open radical hysterectomy. Patients typically spent five days in the hospital before spending an additional 6 weeks at home recovering. Those who needed additional treatment such as radiation and chemotherapy had to wait six to eight weeks to begin treatment. Now, patients go home within 24 hours and can return to work and exercise in three weeks. Curative therapies can begin in about three weeks. The more complex the surgery, the greater the advantage to robotics.
Take the case of a 45-year old woman who underwent an emergency hysterectomy by a general gynaecologist for heavy bleeding. Several days after the surgery, the laboratory reported that the uterus and cervix contained a cervical cancer. Unfortunately, she had the wrong type of operation. If the cancer diagnosis had been known in advance, the simple hysterectomy would not have been performed. Patients with cervical cancer should undergo a radical hysterectomy, a more complex and extended operation intended to remove all the cancer.
In order to correct the inadequacy of the original surgery, the patient now had to undergo a radical parametrectomy, upper vaginectomy, and lymphadenectomy. This is typically a challenging operation performed through a 20-30cm incision with a high complication rate, 1000cc of blood loss, and an extensive recovery. We performed her surgery robotically with 25cc blood loss and five 8mm incisions. The patient was able to go home the next day with a rapid and uneventful recovery.
The daVinci® Surgical System, also known as the surgical robot, is available at hospitals around the world. The technology is expensive, but it is a shared resource utilised by many surgical specialties for a variety of conditions. Current indications in the field of urology include radical prostatectomy for men with prostate cancer, removal of all or part of a kidney for cancer or other conditions, repair of congenital abnormalities in children, and removal of the bladder with reconstruction for bladder cancer.
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In general surgery, physicians are using the robot to perform bariatric surgery for obesity, remove a diseased adrenal gland or portion of the pancreas, and excise portions of the intestine or colon. Cardiac surgeons utilise the system for heart valve replacement and coronary bypass surgery.
In my field of gynaecology – the fastest growing sector of robotic surgery – we use the daVinci® Surgical System to perform hysterectomies for fibroids, endometriosis, uterine cancer, and cervical cancer. Suturing is the key component for two other gynaecologic procedures: myomectomy (removing fibroids without hysterectomy), and vaginal colpopexy (suspending prolapsing organs to the sacrum). The daVinci® Surgical System offers a clear advantage for these procedures due to the enormous improvement in suturing ease and precision.
The technology of the daVinci® Surgical System is best described as computer-assisted surgery. The term surgical robot is actually a misnomer. This implies that the movements are somehow automated, but this couldn’t be further from the truth. The system simply connects the movements of the surgeon to the instruments inside the patient’s body through a sophisticated computer. The system translates each movement of the surgeon’s hands, in real time, to the instruments through a series of tiny pulleys. The surgeon maintains complete control of both the camera and the instruments at all times. There is, of course, a learning curve for the surgeon and the surgical team to adapt to this new technology. After about twenty-five cases, the surgeon gains proficiency and eventually can improve his/her technique and efficiency compared to open surgery or conventional laparoscopy.
The daVinci® Surgical System was introduced more than ten years ago, originally based on technology from the US Defense Department. Initially, the military was looking for ways to stabilise injured soldiers in the field while the trauma surgeon operates remotely from a secure location. Intuitive Surgical Inc. then developed the platform for the operating room in the late 1990’s. Intensive ongoing research and development has been in full swing ever since. The third generation machine is now available with improved optics, a smaller footprint, and greater range of motion.
The primary criticism of this technology is its price tag. In the United States, the system costs about $1.6 million. For programmes that are busy and create models of efficiency, daVinci® surgery has been shown to be more cost-effective than other modalities. Principally, this results from fewer days in the hospital, typically the greatest charge in any hospitalisation. These analyses do not even include the costs of home health care, antibiotics, and complications from more invasive surgical approaches. The savings to society in general from gained work productivity with shorter recovery time more than offsets the cost of this technology. Also, the system is a shared resource that can be utilised by many specialties for many different applications, thus improving the cost to benefit profile. In my own cases, I choose the ancillary equipment in the room with an eye towards cost containment. Other costly instruments, such as stapling devices or electrocautery tools, are no longer necessary. I can perform a typical hysterectomy with just three daVinci® instruments, each costing $200 per use. We utilise non-disposable tools for most of the other aspects of the procedure, saving on medical waste expenses as well.
The current system platform does have some limitations. These include limited application to surgery in multiple areas of the body. If a surgeon needs to operate in all four quadrants of the abdomen, for example, this technology is limiting. It is more effective when the procedure involves only two quadrants, because the arms have to face in one direction. Once the system is set up and docked, moving the whole machine around is cumbersome. In addition, the arms have some limitations as to range of motion. Right now, the instruments are wristed, but they have no elbows. In the future, instruments that can articulate at an elbow would improve range of motion. At this time, the computer is also unable to give the surgeon tactile feedback. Certainly, being able to feel the tissues would add an additional important dimension to the surgeon’s awareness of the surgical field.
In the near future, we anticipate advances that will allow the camera and all the instruments to enter the body through one small incision. In addition, the system will allow imaging through other modalities to be superimposed on the 3-D console image. For example, a fluorescence study of a patient’s lymphatic system could be seen in real time, allowing the surgeon to see cancerous lymph nodes to be targeted for removal while sparing normal ones. It is not hard to imagine that in a few years, technologies we can only dream of today will be incorporated into this system, all resulting in better outcomes for patients with less morbidity. This technology clearly is the future of surgery, and the future looks bright.[/three_fourth_last]