Robotic Surgery Overview

Surgery in 21st Century

Man has always striven to make life easier for himself. From the transition from fires in caves to central heating in his own home, from walking to horse riding to jet setting, he has always made strides to make things convenient and less of an exertion for oneself. Robotic surgery is one such transition. Whilst laparoscopy was an evolutionary step that was for the most part patient-centered, the master-slave robotic systems evolved with the comfort of the surgeon in mind, but maintaining all the advantages of laparoscopy for the patient. In addition they provide 3D vision, allow the surgeon to operate from a remote console, and articulated instruments to perform fine intracorporeal manipulation. This effectively bridges the open and minimally invasive realms of urological surgery thus appealing to the laparoscopy naïve surgeons. Advocates of robotics may in fact state that laparoscopy is the transitional technology, while robotic surgery is the path to the future.

Evolution of robotics in surgery

The concept of automation is credited to Aristotle, from the 4th century BC. The word Robot is derived from the Czechoslovakian robota, which means worker. It first appeared in Karel Capek’s play, Rossum’s Universal Robots, in Prague in 1921.Table-1 lists the evolution of automatons and robots through the ages.

The first use of robotics in surgery was in 1985, when PUMA 560, was used to perform neurosurgical biopsies with precision. This robot was used 3 years later to perform the first TURP (transurethral resection of the prostate). The PROBOT was developed in London specifically for performing TURP. Integral Surgical Supplies then created the ROBODOC to machine the femur; this robot was the first to be approved by the FDA.

In the mid-to-late 80s a group of researchers in NASA Ames Research Center wanted to develop telepresence surgery, which was the main impetus for the development of surgical robots. This team then joined the group at Stanford Research Institute (SRI).

The US Army took interest in their collaborative work with the main aim of reducing wartime mortality by bringing the surgeon to the wounded soldier through telepresence.

Da Vincis Robot of 1495

The idea was to take the wounded soldier to the nearest Mobile Advanced Surgical Hospital (MASH), on whom the surgeon can then operatefrom a remote location. Although animal studies were done, it is not known if human studies have been carried out during real wars.

Commercial ventures eventually took off from this research. Computer Motion Inc. of Santa Barbara, California used seed money provided by the Army to develop the Automated Endoscopic System forOptimal Positioning (AESOP), a robotic arm controlled by the surgeon voice commands to manipulate an endoscopic camera that is fixed to the operating table. Shortly after AESOP was marketed, Integrated Surgical Systems (now Intuitive Surgical) of Mountain View, California licensed the SRI Green Telepresence Surgery system. This system underwent extensive redesign and was reintroduced as the Da Vinci surgical system. Within a year, Computer Motion put the Zeus system into production. With developments in the Da Vinci robot and due to commercial interests, the Zeus system was phased out (Intuitive Surgical bought Computer Motion).

The Development of Automatons and Robots
Year Device
1350 An automated rooster was erected on top of a cathedral in Strasbourg; the rooster flapped its wings and crowed daily at noon.
1495 Leonardo Da Vinci is recorded as being the creator of the first robot in human form. The robot is a knight (see Fig.1) in appearance wearing the traditional for the time, Italian-German armour. Leonardo had created other forms of robotics, including a walking mechanical lion and a spring-powered car, which is considered to be the first programmable computer!
1497 Two bell-striking giants were built on top of a clock tower in Piazza San Marco, Venice.
1560s AmbroiseParé (1509±1590), an eminent surgeon of the Renaissance, invented upper and lower limb prostheses, showing aknowledge of basic prosthetic function. The `Le Petit Lorrain’ was hand-operated by springs and catches for a FrenchArmy Captain. This first mechanical hand was then used in battle.
1738 Jacque de Vaucanson developed a mechanical duck.
1805 Maillardet built an automaton that drew pictures and could write in both English and French.
1876 Life-sized automatons entertained audiences at the World’s Fair
1921 Capek introduced the term `robot’, which replaced automaton.
1940 Westinghouse created two robots, one that danced (`Elektra’) and another a motorized dog that barked and stood on its hindlegs (`Sparko’).
1942 Asimov introduced the term `robotics’.
1948 The transistor was invented, which enabled robots to be developed with the use of computers.
1954 George Devol developed the first patent for parts-transfer machines. Joe Engelberger formed Unimation and was the firstperson to market robots. The industrial robot revolution had begun and the world’s first robot company was established.
1960s Two scientists first coined the term `cyborg’ to mean an intimate interface between person and machine. A portmanteaufrom the terms `cybernetic’ and `organic’, `cyborg’ was constructed when the adaptability of man for space travel wasconsidered.
1960s `Shakey’ was developed to navigate indoor environments and help stack blocks.
1962 General Motors began to use the first industrial robots in New Jersey.
Late 1960s Hughes Aircraft Corp. developed Mobots (Mobile Robots), robots controlled by remote radio systems.

So, what is robotic surgery?

When people hear about robotic surgery, the immediate mental imagery is one of a robot performing the surgery directly without human involvement – I say this because, this is what I get asked quite frequently. All robotic systems used in surgery are master-slave systems.

All this means is that the robot is controlled by a human being and is not totally independent like ‘Chitti’ in the blockbuster movie ‘Endhiran’. Robotic surgery is basically laparoscopic surgery with a few bells and whistles added.

There are three main components of the Da Vinci robotic system (from L to R in picture on the right):

The surgeon console, the patient side cart with the robotic arms and the video processing equipment stack.

How is robotic surgery carried out?

The patient is placed on the operating table, as is the norm for laparoscopic surgery. With the Da Vinci Si robotic system there are 4 robotic arms and therefore ports for these can be placed as required, although insertion of the 4th one is optional depending on the procedure being carried out.

The main port is the camera port, with two additional ports for insertion of robotic instruments. These two ports (as well as the 4th port) are special robotic ports.The 4th arm instrument is ‘switchable’ with the 3rd arm; at a given time either only the 3rd or 4th arm can be manipulated.

Therefore, the 4th arm can be held in a ‘frozen’ position, whilst the 3rd arm is being used. Thus, the 4th arm effectively becomes a passive assistant, obviating the need for a 2nd(human) assistant.

Once the ports have been placed, the robotic cart is then moved into position and ‘docked’ to the ports (see picture on right) – this basically involves securing the robotic arms to the ports using clasps that are present in the arms.

The laparoscopic camera is then inserted into the camera port, following which the other robotic instruments are inserted ‘under vision’. The insertion of ports and docking the robot usually takes no more than 15-30 minutes.We are now ready to operate!

Depending on the procedure, a table side assistant can pass and cut sutures, provide suction, apply clips and assist with dissection, through additional ports.The operating surgeon sits at the console and uses his fingers to manipulate the robotic instruments.

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