FROM THE 14TH INTERNATIONAL CONGRESS AND ENDO EXPO
LAPAROSCOPY UPDATE: ROBOTIC SURGERY COMMITTEE
WILLIAM E. KELLEY, JR., MD
On July 12, 2000, the first computer-enhanced surgical system became FDA approved for abdominal and pelvic laparoscopic surgery in the United States. FDA approval followed in 2003 and 2004 for cardiac surgery, specifically for robot-assisted mitral valve replacement and robot-assisted CABG respectively.
Computer-enhanced surgery provides improved precision through motion scaling technology and electronic filtering. Wrists at the end of the laparoscopic instruments provide 360-degree rotation and flexion within 2 cm of the instrument tips. These mechanical advantages offer the surgeon a precision of movement that cannot be duplicated with traditional laparoscopic or open instruments. In addition, a true 3-dimensional visual system gives the surgeon much more precision with the instrumentation. These mechanical and visual advantages allow most surgeons to be ambidextrous with dissecting and suturing techniques.
At the current stage of development, the computer-enhanced technology has been most useful for complex dissecting and suturing techniques, especially in small, poorly accessible locations. The flexibility of the instrumentation has greatly facilitated dissection and suturing for radical prostatectomy. The majority of centers that currently have robotic systems, many of which had had no previous experience with laparoscopic radical prostatectomy, are utilizing the robot for this technique. Gynecologic applications have thus far been limited to infertility surgery for tuboplasty and tubal reanastomosis.
For general surgery, the instrumentation has shown substantial advantage for laparoscopic Heller myotomy, with a significant reduction in the incidence of mucosal perforation. Other procedures that have been enhanced by this technology include laparoscopic esophagectomy, pancreatectomy, laparoscopic pyloroplasty when performed at the time of antireflux surgery, and suturing the posterior suture lines of Toupet fundoplication.
For vascular surgery, experience is now growing with robot-assisted laparoscopic aortofemoral bypass and laparoscopic aortic aneurysmectomy. In our center, we have experienced hospital stays of 2.5 days following aortofemoral bypass, with the patient returning to normal activities in one week.
Cardiac surgery is probably the most spectacular example of this enabling technology. Multiple centers in the United States and in Europe and Canada have performed mitral valve replacement, as well as CABG. Totally endoscopic coronary artery bypass is now being performed with as little as 2-day length of stay, with patients resuming their normal activities one week following surgery.
The greatest promise of computer-enhanced surgery lies in its future applications. Enhanced precision and flexibility and the ability to deliver highly functional instruments to small awkward locations will empower surgeons to develop new techniques that are not currently feasible with MIS techniques. Robotic surgery could very well stimulate a new evolution of surgery in the decade to follow, as the instrumentation evolves and more flexible platforms for instrument delivery are developed.
www.Laparoscopy.org The Laparoscopic Surgery Information Source
