Robotic Surgery-Patient Guide

Surgery in 21st Century

What is meant by robotic surgery? Does a robot actually operate on me?

Although there have been some robot prototypes that have done certain surgical procedures, modern day robotic surgery is carried out by humans. The robots are actually controlled by the surgeons. This is referred to as a master-slave system. The robot therefore acts as an interface.

Robotic surgery combines the two ways of doing surgery – the traditional open method of operating and the modern laparoscopic way of doing procedures.

Okay, that sounds complicated for us lay people. Can you elaborate, please?

Sure, I will try!
With the traditional open surgery, the surgeon sees everything through a large cut (incision) he has made in the tummy (abdomen). He needs powerful lighting to see the space through the cut he has made, but his (or the poor assistant’s) head can sometimes get in the way casting shadows and preventing him/her doing a good job. Also, since the cut goes through skin, muscle and deeper tissue, in the post operative period there is likely to be a lot of pain. This then requires significant amount of painkillers.

In laparoscopic surgery, instead of making big cuts in the abdomen, small incisions are made, through which special tube like structures are inserted into the abdomen – these are called ‘ports’. The abdominal cavity is filled with gas (usually carbon dioxide).A telescope (laparoscope) is introduced through one of the ports, serving as the surgeon’s ‘eye’. Special instruments are then inserted through 2 or 3 other ports to enable the surgeon dissect, cut or manipulate tissues. A camera is connected to the laparoscope so that the images are displayed on a TV monitor. The surgeon looks at this monitor and performs the surgery. The problem with this modality is that it suffers from the fulcrum effect(see picture on right) –if a task requires moving the tip of the instrument to the right, the operator has to move his hand to the left! This is counterintuitive, but because the human brain is capable of ‘correcting’ this, it becomes learned behavior with adequate training. Also, because one is operating on 3-D structures looking at a 2-D screen, there is parallax error resulting in eye-hand-target misalignment.

I mentioned that robotic surgery combines these two ways of performing surgery. This will be understood better after I explain the actual process of what happens during a robotic procedure.

So, what happens actually during a robotic procedure?

The robotic system consists of the surgeon console – where the surgeon sits and controls the robot, the robotic(or patient side) cart which is connected to the patient and the video stack. The surgeon inserts the ports, as is the norm for laparoscopic surgery. Some of these ports are called robotic ports – these have special configuration so that the clasps on the robotic arms ‘hold’ these ports. The robotic cart is then wheeled to the operating table and the arms of the robot are ‘docked’ to the ports. Once the laparoscope is inserted with the camera attachment – a high resolution 3-D camera system in this instance, the surgeon on the console is able to see the inner part of the body in a hugely magnified way in 3-D. The large screen on the video stack allows the scrub team / assistants to view the procedure in HD. The special instruments that are loaded into the robotic arms are highly articulated mimicking the action of a human wrist (endowrist).

Using pincer like controls the surgeon controls the robotic arms and the instruments loaded through these arms.

The robotic interface allows motion scaling – for example if my hand moves 10cm, I can fix the instrument that I control via the console to move just 1 cm. Also, since tremors are not transmitted via the controls, no more tremors (tremor elimination)!

The surgeon also has access to control an array of accessories, including control over the camera, via foot pedals conveniently located on the console. Since the surgeon is performing almost the entire procedure seated, there is less physical and in turn, mental stress.

Going back to what we started with – the robotic interface allows a surgeon on the console to perform hand motions that mimic almost everything done in open surgery but without making big cuts as in open surgery! Therefore, this is a marriage of the best of open and laparoscopic surgery. Laparoscopic surgery for complex procedures like radical prostatectomy, radical cystectomy and partial nephrectomy is extremely demanding and has a steep and prolonged learning curve. Robotic interface makes this easier to achieve.

To list the advantages of robotic surgery

Robotic interface takes away the major disadvantage of laparoscopic surgery ie the fulcrum effect.

Minimally invasive, therefore faster patient recovery and less need for pain killers.

3-D HD vision that allows precise control over tasks; minimizes blood loss.

Endowristed instruments that enhance dexterity & allows superior reconstruction ability.

Superior ergonomics for the surgeon – less fatigue and therefore greater ability to achieve efficiency.

The disadvantages are:

Unlike in open surgery, the surgeon cannot ‘feel’ the tissues (lack of haptic feedback). The surgeon learns to compensate for this using visual cues.

It is more expensive than open or laparoscopic surgery, but with competition in the horizon to the currently available robotic surgical system, it is anticipated that it will become cost equivalent in the future.

What are the specialties that can use the robotic interface?

There are a number of procedures that can be done with greater precision using the robot. Some of the specialties using the robotic interface today are:

Urology
General Surgery
ENT including Head & Neck Oncology
Gynaecology
Neurosurgery
Transplantation Surgery
Orthopaedic Surgery
Cardiothoracic Surgery

What are the procedures that are typically done in urology using the robot?

Any procedure done laparoscopically can today be done with robotic assistance.

Cancer Surgery

Robotic radical prostatectomy
Robotic radical cystectomy
Robotic partial nephrectomy
Robotic radical nephrectomy
Robotic radical nephroureterectomy
Robotic radical pelvic lymph node dissection

Reconstructive surgery

Robotic pyeloplasty
Robotic augmentation cystoplasty
Robotic fistula repair
Robotic reimplantation of ureter

Transplantation

Robotic donor nephrectomy
Robotic renal transplantation