|Year : 2005 | Volume
| Issue : 2 | Page : 79-82
Robotic-assisted laparoscopic surgery in urology:a historical perspective
Nikhil L Shah, AK Hemal, Mani Menon
Vattikuti Urology Institute, Henry Ford Health Systems, Detroit, USA
Nikhil L Shah
2799 West Grand Boulevard,Vattikuti Urology Institute,K9 Henry Ford Health Systems,Detroit, MI 48202
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Significant improvements in the surgical approaches and management of disease have been made since the advent of antiseptic surgical technique and the widespread use of antibiotics. During the last quarter century, especially in the last decade, however, there has been an indisputable paradigm shift toward the use of minimally invasive surgery for treatment of a variety of diseases. This has benefited the patient in terms of lower morbidity and mortality through less violation of the body's natural protective boundaries. The morbidity in terms of pain, discomfort, and disability often associated with open surgery is due to the process of gaining access to the specific organ or region of interest as opposed to the actual procedure itself. Put another way, the move toward minimally invasive approaches for surgical disease has resulted in superior outcomes, fewer complications, and an overall improvement in health-related quality of life (HRQOL).
Keywords: Robotic surgery; Urology; Telemedicine; Laparoscopy
|How to cite this article:|
Shah NL, Hemal A K, Menon M. Robotic-assisted laparoscopic surgery in urology:a historical perspective. Indian J Urol 2005;21:79-82
In traditional open surgical procedures, the surgeon is accustomed to few limits on flexibility with regard to the use of his or her hands and with body positioning in order to gain access to the operative field. The surgeon's actions are coordinated through a complex, highly integrated and controlled interaction of visual and tactile feedback. During endoscopic and minimally invasive procedures of today, however, this fundamental coordinated feedback is significantly minimized or lost. In addition, the surgeon's actions are further compromised by limitations in the movement of the instruments, something referred to as degrees of freedom (DOF). Furthermore, the 2-dimensional vision present in standard endoscopy and laparoscopy results in loss of the perception of depth, as well as requires a human assistant to control the camera. Although many surgical procedures are currently performed laparoscopically, complex laparoscopic surgery is limited to relatively few experts and centers worldwide. The introduction of robotic-assisted laparoscopic surgery therefore simply serves as a natural extension of traditional laparoscopy, where it offers the inherent advantages of minimally invasive surgery but additionally improves the surgeon's ability to perform technically challenging operations where traditional laparoscopy could not.
The initial concept of robotics in surgery involved operating at a site remote from the surgeon. ,, The ability to transpose technical surgical expertise from one site to a distant site was believed to expand surgical application. Advantages of robotic manipulation for surgical procedures were described as: (1) superior depiction of anatomy (2) consistent movement free of tension and tremor (3) the ability to work in specific planes and regions not amenable to open surgical techniques., To this end, surgical robots were constructed and can be classified into two predominant system classifications, image-guided and surgeon-driven systems. Image guided systems are used to guide and allow for precise access to a specific target of interest through radiographic images provided to it from modalities such as computed tomography (CT), magnetic resonance imaging (MRI) and ultrasonography. Surgeon-driven systems allow the surgeon to directly manipulate the instruments through the robot itself.
Surgical robots have begun to appear on the market over the past few years and given the success of such procedures as robotic-assisted laparoscopic radical prostatectomy at our own institution, academic centers and Urologists around the world are beginning to see the potential value of such systems., ,,, Despite the potential utility of augmenting the surgeon's dexterity and maximizing patient outcome, the cost for such systems remains prohibitively high for standard use. As robotic surgery becomes a therapeutic option increasingly used, it is hoped that expanding clinical use and applicability will help to drive down these costs. Furthermore, the use of surgical robots as training-tools in telesurgery and telementoring for surgeons both in-training and in-practice serves as additional beneficial applications of this technology. ,, The following provides a brief historical review of robotics in urology and the use of such systems for various urologic surgical procedures.
Historical review of robotics in urology
Robotics in medicine is a relatively young field. Although conceptualized and developed much earlier, use of robots in the operating theater did not materialize until the 1980s, where their use was pioneered in the fields of orthopedics and neurosurgery. Much of this lag can be attributed to issues surrounding safety, sterility, and the ergonomics required to accommodate such bulky devices in the operating room. The first recorded surgical application of a robot occurred in 1985, where an industrial robot was used as a positioning device to orient a needle for a brain biopsy. Robotics in urology was slower to develop and initially focused on image-guided systems. The first, developed in 1989 by the Mechantronics in Medicine Laboratory at the Imperial College in London, was the PROBOT , and was used to aid in Transurethral Resection of the Prostate (TURP) and percutaneous renal access. In 1991, their first clinical patient underwent a TURP, where the robot automatically generated a sequence of overlapping cuts in successive larger rings of prostate tissue, thereby rapidly resecting hyperplastic tissue. Despite the successful performance and accuracy of the robot, advances in medical management for BPH coupled with the success of the traditional TURP hindered any possibility for widespread use of the PROBOT. Nevertheless, its use marked the first application of a robot in removing such large amounts of human tissue.
In 1994, Potamianos et al. from the Imperial College in London also investigated their robotic system created to assist with percutaneous access to the kidney which consisted of a passive, encoded-arm and a 5-DOF manipulator equipped with electromagnetic brakes placed directly on the operating table. Similarly, in the mid-1990s, the medical robotic research group at Johns Hopkins University (URobotics laboratory) in conjunction with researchers at IBM developed the concept of the Remote Center of Motion (RCM) and implemented this onto a robot named LARS . RCM is a mechanism used by the surgical manipulator to enable a pivoting motion of the instruments centered around a fixed axis on the robot. The LARS robot was an active robot consisting of a bi-planar fluoroscopy imager and was used extensively for percutaneous renal access in the experimental setting and led researchers at Hopkins to develop an improved image-guided percutaneous access robot named the percutaneous access of the KidneY -RCM ( PAKY ). In addition to RCM technology, this robotic system also contained computer software that allowed the robot to mimic and subsequently make minute adjustments to improve the operating surgeon's technique. The newest generation of percutaneous access robots at the URobotics laboratory from Hopkins is the Tracker ., Being much smaller than its predecessors, this system is mounted directly onto the CT table and enters the scanner with the patient. Percutaneous access can therefore be achieved within a confined space without interfering with image quality or functionality of the scanner. The Tracker is now under clinical trials.
At the Politecnico in Milan, Italy, Rovetta and associates have clinically evaluated a robot for transperineal and transrectal ultrasound (TRUS)-guided prostatic biopsy., The surgeon reviews images from the ultrasound and the robot is directed to obtain samples from a pre-positioned needle percutaneously. Although initial reports have shown considerable accuracy and success, it appears that both expense and extensive set-up time as compared to traditional methods will prevent any possibility of broad clinical use.
In 1994, an American company called Computer Motion was the first to obtain FDA approval for the use of the AESOP™ (Automated Endoscopic System for Optimal Positioning, Computer Motion Inc., Goleta, CA) robot arm in the operating room, and was perhaps the most successful commercial surgeon-driven robotic system in the late 1990s., In contrast to image guided-systems, these continuously take the surgeon's input in real time and translate this into corresponding adjustments of the robotically controlled instruments. Augmentation of the surgeon's movements by the robot serves to enhance the manipulative capabilities of the surgeon by eliminating tremor, improving resolution of vision and access to confined spaces, and improving perception and judgment. The main function of the AESOP™ was to hold and orient the laparoscopic camera under voice-, hand- or foot-command guidance. Using 6-DOF for its surgical manipulators, the robot was more compact than its predecessors being easily mountable on the OR table. The AESOP™ has enjoyed many reported successes in a variety urologic laparoscopic procedures such as pyeloplasty, nephrectomy, lymph node dissections, and bladder neck suspensions.
Cornum and Bowersox have reported using a remote-operated system for open surgical procedures at the Stanford Research Institute (SRI, Menlo Park, CA)., This system includes 3-dimensional video and audio communications as well as two tele-operated 7-DOF manipulators, which have allowed surgeons to perform surgery remotely with only a surgical assistant scrubbed and in the operating theater. Initial in vivo trials have been successful in porcine nephrectomies, as well as bladder and urethral repairs after experimentally induced injury. Human clinical application has yet to be described.
In the same genre of the systems developed at SRI, Intuitive Surgical Systems (Sunnyvale, CA) has developed the daVinci™ surgeon-driven robot for laparascopic surgery and received FDA approval in 2001., This is a 'purpose-designed' system consisting of a three-armed robot connected to a remote surgeon console. The surgeon operates the system while seated at the console. Foot pedals are used for control and 3-dimensional displays provide a unique and novel depiction of the surgical field not previously incorporated in other systems. Typically, 5-10 mm ports are used for the instruments which possess 7-DOF including rotation capabilities and a special robotic Endowrist . Experience in our own center has proven that the typical long learning curve associated with performing laparoscopy especially with a technically challenging operation such as radical prostatectomy can be facilitated with use of the daVinci's robotic system.,, To date, many academic and private centers in the US and abroad have used the daVinci™ to perform a variety of urologic procedures such as radical prostatectomy, nephrectomy, lymphadenectomy, and pyeloplasty.,
The Zeus™ is another surgeon-driven system (Computer Motion Inc., Goleta, CA) made by the creators of the AESOP™., It is similar to the daVinci™ in that it consists of a combination of robotic arms and a remote surgeon's console. Of its three arms, it uses an AESOP for the laparoscope and the other two to hold surgical instruments. Although the Zeus™ has been touted as safer and requiring less pre-operative set-up time, it has been faulted for it's lack of dexterity with regard to its instruments when compared to the daVinci™., In September 2002, Computer Motion obtained FDA approval for a new Microwrist , which functions similar to the Endowrist used on Intuitive's system.
Current and future applications of robotic surgery
Current applications of robotics include surgical assistance, dexterity enhancement, systems networking and image-guided therapy. Present systems, however, lack the capability of reproducing tactile sensation, otherwise known as haptics , which serve as a major limitation cited by many critics of robotic-assisted surgery as compared to traditional open surgery., Efforts into developing and investigating new tactile sensors are underway. As experience and technology in robotic-assisted surgery continues to grow, introduction of tactile sensors may add a new dimension to minimally invasive surgery.
Telementoring and telesurgery are perhaps some of the most exciting applications of robotics in surgery. Telementoring describes the assistance of an experienced surgeon in a remote operation, whereas, telesurgery is the active involvement in the operation by manipulating the robot from a remote site away from the patient., In our institution, teleconferences have been used to broadcast robotic surgery for radical prostatectomy. We believe that patients and physicians could benefit from having an expert readily available for consultation. Tele-consulting has been shown to improve medical decision making, patient outcomes and medical training.,, Initial reports of telementoring in urology were published in 1994 following a variety of surgical procedures by Dr Kavoussi and associates. In addition, at our institution as with others, we see a very real role of the robotic as a surgical training tool. Laparascopy is a skill that requires initial training followed by constant exposure in order to remain facile and skilled. In concert with simulations and perhaps virtual reality, it may become possible to perform virtual operations in order to gain experience before moving to human patients. Nevertheless, we believe that introducing Urologists not experienced with Laparoscopy to laparoscopic procedures such as nephrectomy and prostatectomy, may find it easier to perform robotic-assisted laparoscopy as opposed to traditional Laparoscopy for many of the reasons outlined above.
| Conclusion|| |
Robotic-assisted laparoscopic surgery offers a wide-range of possibilities towards improving current surgical technique as well as allowing for the possibility of creating newer and improved approaches to improve quality and patient outcome. Advantages of surgical robotic systems especially in areas such as improvement of the precision of manipulation and imaging enhancement are great. Although still in its infancy, the success of robotic use in the operating theater and for percutaneous procedures is incontestable. With ongoing improvements in hardware and software, the application of surgical robots will only increase. Other important factors that will determine the future application robots in clinical practice will be not only the costs associated with such technology but perhaps most importantly - physician acceptance. Finally, the impact of such technology for academic and training purposes such as operative simulations, as well as telementoring and telesurgery remain to be established, but do offer exciting possibilities for the future.
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