Robotic Surgery: The Technology, Benefits and Risks

The words 'Robotic Surgery' may at once inspire a sense of awe or strike fear in the heart of a patient. You may, depending on your view of technology, be amazed at the advancement in technical wizardry and start to think about the advantages. Or you may equally be petrified with fear - Put my body at the mercy of a robot? What if things go wrong? Why do they want a machine to operate on me? Have they run out of surgeons?

Firstly lets deal with the major miconception- as it stands now, Robotic surgery is actually 'Robot Assisted Surgery'. It does not eliminate the human surgeons but merely assists them.

The Training, intuition, the skills, the instincts, the vast knowledge and experience of the surgeon is not lost in this method but merely enhanced.

I hope to introduce you to the concept, the technology, its benefits and some potential disadvantages in the course of this hub. So welcome to the world of Robot Assisted Surgery.

Using instruments to enhance surgical precision and skill is not new. Over years Surgeons has developed and honed instruments to aid examination, obtain measurements and perform surgical procedures. Several archaeological digs have unearthed fascinating finds in surgical instruments from ancient Egyptian, Indian, Greek and Roman cultures.

These instruments were and are developed to increase accuracy, develop precision, minimise damage, decrease human error, reduce pain, scarring and recovery periods.

The Robotic systems are no different from these ancient intentions.

In addition there is a new reason for developing Robotic systems- remote surgery. As surgery becomes more and more complex and each surgical specialty branches out more and more, it is difficult for every surgeon to be an expert in every procedure.

Often the person most suited to conduct a particular surgical procedure may be thousands of miles away. with the availability the remote equipment- the expertise required is transferable across airwaves and a surgeon in one continent would be able to operate on a patient in another with the availability of robotic equipment thus providing instant access to expertise without having to travel thousands of miles.

• Space Exploration ( Mars Landing, Repairing satellites)
• Agriculture ( planting, harvesting, fertilising)
• Military Expeditions ( Remote spy planes, missile launch, offensive weaponry)
• Manufacturing ( Cars, computers, Cameras and million other uses)
• Clean up Hazardous materials ( Radiation leaks, Chemicals, toxic fumes etc)
• Rescue Missions ( Earthquakes, Fires, Explosions)

We all have heard of Laparoscopic surgery - this is a technique through which rather than open up the abdomen in full, tiny incisions are placed to insert a scope/camera, two instrument ports are then introduced. The surgeon then operates through these ports using the enhanced vision available through the camera. This method has been in use now for decades and has been very successful.

As this still requires a surgeon to manipulate the arms and also to wiled the instruments, surgeons realised that despite the minimally invasive nature and advantages of reduced scarring and reduced tissue manipulation, it was hard to eliminate the lack of biofeedback, any natural tremor that may come from holding the instrument for a long time in awkward positions.

At the same time US Military has been quietly spending millions in developing remote medical intervention units to aid battlefield surgeries and the possibility of using robotic arms ( they were already trying this in bomb disposal and exploring dangerous terrains). NASA has already demonstrated that remote sensors can be used to collect soil samples and make readings in distant space.

The Use of Robotic surgery is not new. The very first use of Robotic surgical intervention dates back to 1985 to perform a neurosurgical procedure. PUMA 560 was used in performing a guided brain tissue biopsy successfully.

Within three years, PROBOT was developed and first used to perform Prostate surgery for Men at Imperial College London. Soon an avalanche of possibilities began.

A fully functional Telesurgery Robotic system was gradually developed with collaborative work from several agencies including NASA. Intuitive Surgical trialed and marketed the Da Vinci surgical system which has since been FDA approved and in widespread use.

The current system in widespread use, Da Vinci Surgical system is essentially made up of three elements:

• A Surgeon's Console with remote controls for operating

• A High Definition 3D Visioning system

• A Patient Side Cart with 4 mechanical arms ( one for controlling the camera and three to hold instruments and perform)

The patient has four ports or cannulae inserted into them which 'dock' onto the four mechanical arms. these ports allow visualising and operating conduits.

The improved visual assistance through the 3D HD technology means everything can be magnified and enhanced to aid mobilising even the smallest vessel while performing highly precise operating movements that are impossible by the human eye- human hand combination.

A human assistant can also participate if needed using additional ports.The Highly refined robotic arms can perform clear, precise and delicate dissection, suturing, anastomosing, and excising by reducing tremor, enhancing skilled movements and eliminating imprecise gestures.

Minimally Invasive

As with laparsocopy , the use of small and precise portals means that the patient doesn't require very long incisions to open up the body. Small incisions mean less scarring while allowing the same degree of access.

Enhanced Imaging

The 3D HD imaging system is state of the art and capable of magnifying the organ under surgery multiple times. This allows the surgeon to visualise tiny blood vessels, zones of separation and dissection precisely and clearly and allows better procedural decision making.The Three Dimensional imaging gives a fully immersive experience in surgery.

Control and Precision

The Robotic arms that hold the instruments have enhanced Degree of Freedom ( DOF) that allows a 360 degree level of manipulation that improves upon the human hand. The restrictions placed by muscle fatigue and natural physiological limitations are clearly eliminated and the hands retain their precision as much at the end of a long surgery as they do at the beginning.

Database of Expertise

The Robotic device has computerised memory that can store thousands of surgical procedures and hold a database of expertise that can be drawn upon. This is of advantage to every surgeon and may prompt the move to fully independent robotic procedures! A robot performed a surgery for a man with heart arrythmia by using fully Artificial Intelligence systems in 2006. This is being explored further for simple and more complex procedures.

Remote Performance and Telemedicine

although originally developed with an intention of remote operability, the system is now mainly used as on site assistance with the surgeon present in the room. The advances mean that soon the surgeon may be able to operate from a distance, even thousands of mile away. Great way to access expertise from around the world and collaborative working. Not so great if you are a surgeon taking a holiday!

There are no major disadvantages to the system that cannot be overcome- however the prohibitive cost, the need for intense training, Lack of tactile feedback instrument failure have all been cited as possible causes for worry.

Prohibitive Cost

The system costs in the region of 1.5 million dollars and add to this the cost of supplies, maintenance and training. This will escalate the cost of each procedure considerably. However, savings may be made elsewhere with reduced team, reduced hospital stay, reducing complications.

Steep Learning Curve

As with most new technology the surgeon is forced to learn new methods, new technology and need to develop new skills in biofeedback. However, as more on more surgeons come on board and a new generation of medical students used to video game controllers and remote technology will find it considerably easier- this could also become part of core surgical training at varying levels.

Lack of Tactile Feedback

Experienced surgeons also rely on tactile feedback on the organs they handle in order to develop an intuition on what the issues are, where to dissect etc. This is lost in Assisted surgery- however, the enhanced visual feedback and immersive imaging, the use of precision tools and techniques may make up for this.

Instrument Failings

We all worry about instrument failure. but this is nothing new- foolproof systems and backups are built in just as in airline travel, cars and other day to day technology. While this could be something feared, rationally we face these risks everyday and instruments are far less susceptible to erroneous behaviours than humans in many cases.

• Gastroenterology: Liver Resection, Pancreatic Cancer, Cholecystectomy ( Gall Bladder), Bariatric ( Stomach shrinking)
• Cardiothoracic: Endoscopic Coronary Artery Surgery, Mitral &Aortic Valve Repair, Oesophagectomy, Lung surgery
• Cardiology: Arrhythmia reversal, Conduction systems
• Gynaecology: Fibroids, Uterine Cancers, Tubal procedures, Hysterectomy, Cancers
• Urology: Prostate, Nephrectomy, Bladder procedures, Kidney tumors .
• Orthopaedics: Joint replacement, Ligament surgery such as Anterior Cruciate of Knee, Arthroscopy for joints and other procedures
• Paediatrics: Cardiac procedures, diaphragm repair, congenital defects such as tracheoesophageal fisturla, herniae etc.
• Neurosurgery: Epilepsy eradication, Parkinsons, tumor removal, pituitary, biopsy

Robotic surgery has grown tremendously over the last decade and is one of the fastest growing innovations in the field of surgery. There is an expanding evidence base and a long line of patients who have benefited from this.

Every specialty is now considering the use and there are many examples of areas where robot assisted surgery is evolving. In fields such as Cardiac surgery, Abdominal and Pelvic surgery there is a well established experience base. In Men's health Robot assisted Prostatectomy have fast replaced any traditional ( and cruder) methods. Other fields follow. On the right is a list of areas where robot assisted surgery is emerging as front runner.

The most commonly offered procedures are in the field of Cardiology, Gynaecology and Urology.

Many innovative techniques are being pioneered for the future in delicate areas such as Eyes, Ear, Nose and throat and many more.

Anyone who demonstrates a healthy level of concern with robot assisted system is right to do so. In the past people have understandably been cynical and fearful of new innovations: planes, trains, automobiles and many medical interventions. This is our evolutionary prerogative.

It is worth remembering a few points:

• Robotic surgery is actually Robot Assisted surgery- The surgeon is still fully in control
• It enhances the skills rather than reduces it
• It minimises several complications and enhances recovery
• It does still need the Surgeon to take a lot of training and development
• It is very expensive now but may get cheaper
• If given an option of traditional versus robotic surgery, I perhaps will choose robotic depending on the surgeon's expertise, the procedure and the hospitals reputation.

Hope this article has helped inform and alleviate some doubts in your mind. Always consult with your surgeon with an open mind and be well informed before.