Laparoscopy Today

CONFERENCE REPORT: Computer Enhanced "Robotic" Surgery

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

JOURNAL WATCH: Fertil Steril Robotics

Robotics in Reproductive Medicine • Dharia et 2005;84:1-11. In this modern trends article, Drs Dharia and Falcone review the history of robotics in surgery and detail the roles (including training, telementoring, and telepresence) of these complex machines in gynecology and its subspecialties. Several types of robots and their current applications in gynecology are discussed.

www.Laparoscopy.org  The Laparoscopic Surgery Information Source

JOURNAL WATCH: JSLS Robotic Systems and Surgical Ed

Robotic Systems and Surgical Education • Di Lorenzo N et al 2005;9:3-12. Robotic systems can serve as tools for resident as well as experienced surgeon education. The use of robotics for surgical training has the potential to reduce the learning period, provide a system to check for errors, and allow for an evaluation of the skills obtained.

www.Laparoscopy.org  The Laparoscopic Surgery Information Source

Remote Telepresence Surgery

SEPARATION OF SURGEON AND PATIENT

MEHRAN ANVARI, MD

The ability to perform an operation on a patient hundreds or thousands of miles away from the surgeon was initially conceived as a means of offering emergency surgical care in extreme environments, such as a battlefield or in space. In fact, the first surgical robotic prototypes were funded by DARPA and NASA grants to meet exactly such a vision.

The first robotic-assisted remote telepresence surgery using an early prototype of the da Vinci robot developed by Stanford Research Institute was performed successfully by Drs. Rick Satava and John Bowersox in 1996 (Figure 1) [1,2]. It was, however, Prof. Jacques Marescaux and his team from IRCAD who in September 2001 performed the first clinical robot-assisted remote telepresence surgery (RARTS), a laparoscopic cholecystectomy, using a specially adapted ZEUS robot (Computer Motion, Goleta, CA) on a patient 7000 km away from the primary surgeon (Figure 2) [3]. Our team at the Centre for Minimal Access Surgery (CMAS) in Hamilton, Canada, has now performed 22 RARTS on patients 350 km away in the northern Ontario town of North Bay (Figure 3). Our ability to successfully perform complex surgical procedures ranging from laparoscopic Nissen fundoplications to laparoscopic anterior resections has demonstrated the viability of remote telesurgery in the dissemination of surgical expertise and delivery of surgical care to remote patients [4].

In October of 2004, a crew of 3 astronauts from Canada and the USA took part in NEEMO 7 (NASA Extreme Environment Mission Operation) and conducted several telesurgical experiments while living in a saturated environment in a laboratory 50 feet underwater 5 miles off the coast of Key Largo, Florida. The crew was aided by a surgical team from CMAS through Internet telecommunication and were able to successfully perform surgical procedures including cystoscopy and stone basket retrieval of a ureteric stone, repair of arteries, and laparoscopic cholecystectomy on artificial cadavers (Figure 4). The 3 astronauts were not surgeons, and one was not even a physician, yet they were able to successfully complete all the surgical tasks at a level expected of a resident in surgery using telementoring and simple telerobotic assistance.

NEEMO 7 proved that the original concept of delivering emergency surgical care in the absence of a surgeon is feasible. However, the current size and weight of the robotic platform prohibited NEEMO 7 from utilizing RARTS as a means of delivering direct emergency surgical care by a remote surgeon. For RARTS to work in an extreme environment, we need a drastic departure from the current surgical robotic platform design. Surgical robots need to become more modular, robust, easily assembled, and significantly smaller and lighter. In addition, surgical robots have to be able to perform tasks in collaboration with humans and become aware of other assistants and objects in their vicinity. Furthermore, the ability to use a variety of different telecommunication technologies available, from simple Internet to fiberoptic lines, to satellite, will make such a platform usable in all environments. A number of centers including ours are engaged in design and development of such robotic platforms, and it will not be long before programming of semi-intelligent robots will allow for RARTS in environments with long telecommunication latency (>1 second).

Future robotic evolution and development will allow remote telepresence surgery to perform a larger role in everyday surgical practice, help disseminate knowledge, provide expert surgical care at a distance, and save lives in extreme and isolated environments.

Figure 1. (A) Dr. J. Bowersox demonstrates the surgeon’s console of the Medical Forward Area Surgical Telepresence (MEDFAST) system to Alan Alda. This was a prototype robotic-assisted telesurgery system developed to provide immediate surgical support in combat conditions. (B) MEDFAST. This view, taken during field trials of the system, shows the field surgeon in the mobile unit working with the off-site surgeon who is controlling the robotic arm, to provide immediate surgical care to wounded soldiers. (C) The MEDFAST Mobile Unit. (photographs courtesy of Dr. R. Satava).

Figure 2. (A) Prof. J. Marescaux of Institut de Recherche contre les Cancers de L‘Appareil Digestif (IRCAD) performs the first transatlantic robotic assisted remote telepresence laparoscopic cholecystectomy. The surgeon’s console of the Zeus robotic platform for the “Lindbergh operation,” was located in Manhattan New York City. (B) The patient-side view of the Lindberg operation. The patient and the robotic arms were located in Strasbourg France, a distance of approximately 7000 km from Prof. Marescaux. (photographs courtesy of Prof. J. Marescaux)

Figure 3. (A) Dr. Anvari in the CMAS Robot Control Room during a telerobotic surgery. CMAS uses a Zeus TS robotic platform to work with the local surgeon in North Bay, connected via an IP-VPN network. (B) A view of the operating room in North Bay, showing the robotic arms.

Figure 4. NEEMO 7:  Astronaut Robert Thirsk performing a laparoscopic cholecystectomy in the Aquarius Underwater Habitat off the coast of Florida with the aid of telementoring and telerobotic assistance from Dr. M. Anvari in Hamilton Ontario. NEEMO 7 was a joint project of CMAS, CSA, NASA, and TATRC, evaluating the use of telerobotic surgery in extreme environments.

Address reprint requests to: Mehran Anvari, MD, Centre for Minimal Access Surgery, 50 Charlton Ave, E Hamilton, Ontario, Canada, L8N 4A6. Tel: 905 522 2951, Fax: 905 521 6113, E-mail: anvari@mcmaster.ca

Mehran Anvari, MD, is a Professor of Surgery and Director of Surgical Research at McMaster University. He is the founding Director of the Centre for Minimal Access Surgery, the first Canadian centre dedicated to the promotion of minimal access techniques in all surgical specialties and was recently appointed to the newly established Chair in Minimally Invasive Surgery and Surgical Innovation. His research interests include the use of surgical robotics and he recently established the world’s first telerobotic surgical service between a tertiary institution and a distant community hospital.

References

1.    Bowersox JC, Shah A, Jensen J, Hill J, Cordts PR, Green PS. Vascular applications of telepresence surgery: initial feasibility studies in swine. J Vasc Surg. 1996;23:281-287.

2.    Bowersox JC. Telepresence surgery [editorial]. Br J Surg. 1996;83:433-434.

3.    Marescaux J, Leroy J, Rubino F, et al. Transcontinental robot-assisted remote telesurgery: feasibility and potential applications. Ann Surg. 2002;235(4):487-492.

4. Anvari M, McKinley C, Stein H. Establishment of the world's first telerobotic remote surgical service for provision of advanced laparoscopic surgery in a rural community. Ann Surg. In press.

www.Laparoscopy.org  The Laparoscopic Surgery Information Source

JOURNAL WATCH: JSLS Standard to Robotic Laparoscopy

Making the Transition From Standard Gynecologic Laparoscopy to Robotic Laparoscopy • Ferguson JL et al. 2004;8:326-328. It is suggested that robotically assisted laparoscopic tubal ligation using the Parkland method is a satisfactory procedure to provide transition for gynecologic surgeons and operating room personnel to gynecologic robotic surgery.

www.Laparoscopy.org  The Laparoscopic Surgery Information Source

CONFERENCE REPORT: Robotic Surgery Update

FROM 13TH INTERNATIONAL CONGRESS AND ENDO EXPO

Robotic Surgery Update
presented by William E. Kelley, Jr, MD

Three-dimensional reconstructions will revolutionize all we do. Robot-assisted minimally invasive surgery and computer-integrated surgical systems are being used to improve surgical outcomes in patients. Robots are being applied in different types of surgery. For example, Robodoc is used for precise drilling of the femoral shaft. But is a robot better than minimally invasive surgery? From the surgeon’s perspective, robots provide better vision with a magnified field light intensity and 3D viewing. Robots provide 6 degrees of freedom, whereas in minimally invasive surgery only 3 degrees of freedom are available. Robots are more precise, with no tremor, and more flexibility (7 degrees of movement that are simultaneous and fluid, direct and intuitive, and with ambidextrous torsion). Robotic-assisted surgery is as safe and efficacious as traditional minimally invasive surgery; but, it takes longer to perform and is more expensive. However, as with VCRs and DVD players, in time, the price will decrease. Robotic surgery has been most advantageous in radical prostatectomy, aortofemoral bypass, and CABG. Results in prostatectomy show better outcomes with robotic than with traditional open surgery. In cardiology, robotic surgery has been used in mitral valve replacement with reduced the length of hospital stay. Robotic CABG and totally endoscopic CABG have dramatic benefits for cardiac patients with decreased hospital stay and no driving restrictions following surgery. In addition, surgeons with no minimally invasive surgery experience have a very short learning curve.

www.Laparoscopy.org  The Laparoscopic Surgery Information Source

Advancing Technology: Addressing the Moral and Ethical Issues

PRESIDENTS CORNER

RICHARD M. SATAVA, MD

Remarkable change in the face of medicine and surgery has occurred in the past decade. The prospect for the future is that even more remarkable disruptions will occur. Ten years ago cloning was a theoretical possibility; now, human clones exist. Minimally invasive surgery was emerging and robots were speculated upon; now, robotic surgery is common place. Training was accomplished by didactic lectures and mentorship in the OR. Didactic lectures provided knowledge to young physicians, and mentorship provided technical skills, all during a fixed period of time during residency. Now, however, simulators for objective assessment of skills and the setting of performance criteria before a resident is allowed to operate on a patient point to the time when residents train until they are competent, regardless of the length of the “program.” Residents will train on “virtual” patients rather than real patients, making mistakes before entering the operating room. Work hours are being mandated, perhaps changing medicine and surgery from a profession into a job (How soon before we “punch the clock”?).

Much of the turmoil that is occurring is due to the incredible rate of change in technology. Medical advances are now occurring exponentially (rather than linearly), and society and health care cannot keep up with the pace of change. A prime example is Dolly the sheep, which confirmed the whole theory of cloning and precipitated a “ban” on human cloning, only to have the ban circumvented, resulting in human clones today. Yet Dolly is only the tip of the iceberg; even more profound changes are about to occur, and medical professionals, especially surgeons, have not engaged in discussing the solutions to the soon-to-emerge dilemmas. A few of those issues need to be addressed now, because their remedies will take decades (not months or years) to resolve. Some examples include the following:

Computers are rapidly becoming “smarter” than humans. The human brain computes at 4 x 1019 computations per second (cps). The fastest computer, ASIC Red at Sandia National Labs, computes at 35 teraflops per second (3.5 x 1016 cps). That means that in the next 1 to 2 decades, computers–or robots or machines–will compute faster than humans compute. Will such computers be intelligent? And if so, will humans be able to communicate with them? Will these computers become smarter than humans? Will they remember we made them, or even need us humans any more? If they are “intelligent,” can we pull the plug?

Advances in understanding aging lead to the discovery of the apoptosis factors and to the role of telomeres. By administering antitelomerase (a protein that blocks the enzyme that shortens telomeres during cell division), a breed of mouse has been created that has a life span more than 3 times the normal. Can we apply antitelomerase to humans (or should we), and will it result in humans living 2 to 3 times longer than the possible human life span, for example, living to be 200 to 250 years old? Will such humans be healthy, when will they retire (age 175?), how long will they have the ability to reproduce, what will happen to the planetary population, etc?

Artificial organs are being “grown” by a number of research teams. Within the decade, it will be possible to grow replacement organs from an individual’s own stem cells, so surgeons of the future will only have 1 operation per organ system, ie, take out the old and replace (not repair) it with an new synthetic organ. When all of one’s organs have been replaced with either synthetic organs or smart prosthesis, will that person still be human? What will it mean to be human when your entire body has been replaced with synthetic parts?

While such questions are seemingly science fiction, remember that at the beginning of 1957 no rockets had been launched, airplanes were just becoming commercial, and the moon was for lovers only. Yet within 12 years, we saw Sputnik (1957) and a man walk on the moon. Anyone in 1957 who would have predicted that a man would walk on the moon would have been dismissed as an irresponsible dreamer, yet our technologies exceeded our wildest dreams.

The purpose of these examples is to demonstrate that what has been considered “unthinkable” science is soon to become reality. With these new discoveries, the impact upon society will be even greater than ever imagined–people living 200 years, synthetic bodies, direct brain-to-brain communication, and other such possibilities. Many of these scientific innovations will result from discoveries in health care and surgery. These new discoveries raise moral and ethical issues that will take decades to resolve because societal resolutions to moral and ethical issues cannot keep up with the fast-paced changes taking place in science. Now is the time to begin addressing moral and ethical concerns within the context of the clear and measured reason of discourse, rather than in a crisis mode in reaction to a new scientific discovery like human cloning. The above-mentioned and many other incredible discoveries will occur within the decade, and today’s residents and young physicians will have to face their consequences, for better or worse. We must encourage debate upon these issues–even if they seem somewhat fantastic–through presentations at meetings as well as by teaching our students and establishing biomedical ethics curricula within our surgical training programs. The future has forever been altered.

Address reprint requests to: Richard M. Satava, MD, University of Washington Medical Center, Department of Surgery, 1959 NE Pacific St, BB430, Box 356410, Seattle, WA 98195. Tel: 206 616 2250, Fax: 206 543 8136, E-mail: rsatava@u.washington.edu

Richard M. Satava, MD, is a Professor of Surgery at the University of Washington School of Medicine, a Special Assistant in Advanced Technologies at the US Army Medical Research and Material Command in Ft. Detrick, Maryland. Dr Satava’s prior military appointment was as Professor of Surgery at Yale University, Professor of Surgery in the Army Medical Corps assigned to General Surgery at Walter Reed Army Medical Center.

Dr Satava’s undergraduate training was at Johns Hopkins University Medical School and Hahnemann University of Philadelphia, internship at the Cleveland Clinic, surgical residency at the Mayo Clinic, and a fellowship with a Master of Surgical Research at the Mayo Clinic. He has served on the White House Office of Science and Technology Policy Committee on Health, Food and Safety, is past President of SAGES, the President of  SLS. Dr Satava has been continuously active in education and surgical research with over 175 publications.

www.Laparoscopy.org  The Laparoscopic Surgery Information Source

Robotic Surgery: The Promise and Early Development

COVER

WILLIAM E. KELLEY JR, MD, FACS

The Evolution of Minimally Invasive Surgery. The concept of minimally invasive surgery (MIS) originated in the early 20th century when European gynecologists, and subsequently European surgeons began endoscopic evaluation of the abdomen and pelvis as a diagnostic technique. In 1966 Kurt Semm, M.D. performed several laparoscopic procedures using an automatic insufflator [1], and subsequently developed many endoscopic gynecologic procedures, thereby founding the era of laparoscopic surgery. During the 1970’s and 1980’s, isolated surgeons, such as Berci, Cushieri, and Warshaw, championed laparoscopy as an important diagnostic and staging technique [2-5].

The technique of laparoscopic cholecystectomy was developed independently, and at first quietly, by German surgeon Eric Mohe, in 1985 [6], by the Frenchman, Philip Mouret in 1987 [7], and by Americans, McKernan and Saye in 1988. Shortly thereafter, Reddick and Olsen performed the first US series of laparoscopic cholecystectomy and refined and propagated the technique among general surgeons.
The basic techniques of laparoscopic cholecystectomy were rapidly embraced by the surgical community, and laparoscopic cholecystectomy became the standard of care by late 1990. Laparoscopic techniques and instrumentation were refined and expanded to most areas of digestive surgery over the subsequent two to three years. Postgraduate courses in advanced laparoscopic surgery, including colorectal surgery, were commonplace by 1991. However, the advanced laparoscopic procedures were relatively slow to be embraced by general surgeons on a broad scale because of perceived limitations of the laparoscopic techniques [8]. By the year 2000, less than 3% of colon resections were performed by MIS [2].

Limitations of MIS and the Promise of Robotics. Most advanced laparoscopic procedures require suturing techniques, precise dissection involving delicate structures, and/or the manipulation of significant vascular structures. Many surgeons felt that the limitations imposed by laparoscopic techniques made the advanced procedures too hazardous, tedious, and time-consuming when performed by MIS. The important limitations include impaired visualization caused by two-dimensional visual systems and awkward, often unreliable manipulation of the visual field by nurses or junior house staff holding the laparoscope. Moreover, the instruments are very long and operate through a fixed fulcrum at the abdominal wall trocar sites, resulting in limited range of motion, restricted access to non-contiguous structures, reversed or counter-intuitive response of the instrument tips to movements of the hand, diminished tactile feedback, and exaggeration of natural tremor. The limitations of access and of instrument motion, and two-dimensional vision make suturing and knot tying difficult to master and contribute heavily to the longer learning curve of complex operations. The long length of the instruments compromises the ergonomics of MIS and the limitations of access contribute significantly to surgeon fatigue and discomfort, especially during the somewhat longer, advanced procedures early in the learning curve.

Computer enhanced instrumentation has long been recognized for its potential to solve the limitations of laparoscopic surgery. Visual systems could be controlled by the surgeon and held steady, without fatigue or distraction, by a robotic arm. The potential for three-dimensional vision would improve the dexterity and precision of both fine and broad movements. Motion scaling can translate large, coarse hand motions into fine movement by the instruments, and electronic filtering can remove all tremor from the instrument. Robotic software allows camera and instrument movement to be direct and intuitive, electronically removing the fulcrum effect at the trocar sites. Perhaps most importantly, robotic instrumentation can place a joint or a wrist near the tip of the instrument, producing deflection of the effector tip of the instrument vertically (pitch) and/or laterally (yaw), resulting in one or two degrees of motion at the point of impact that are not available in traditional laparoscopic or open instruments. Robotic instruments respond as though the surgeon’s fingertips were at the end of the instrument, directly holding the needle, scissor tips, scalpel blade, energy source, or grasping tips at the point of impact with the tissue. The cumulative effect of these robotic characteristics is a dexterity and precision that cannot be duplicated by human hands or traditional instruments.

The Evolution of Robot-Assisted MIS. The first commercially available robotic surgical instrument, RoboDoc® (Integrated Surgical Systems, Sacramento, California), was designed for orthopedic surgery in 1992. Orthopedic surgeons can achieve a 75% accuracy drilling the shaft of the femur with traditional instruments, but with RoboDoc® the precision improves to 96% [9]. The first surgical robotic instrument for abdominal surgery was designed to hold and manipulate the laparoscope during minimally invasive surgery. AESOP® or Automated Endoscopic System For Optimal Positioning (Computer Motion, Santa Barbara, California) was FDA approved in 1994. AESOP® gives the surgeon complete control of the laparoscope and provides a stable visual field directed by voice commands from the surgeon. The first integrated robotic surgical system for clinical application, da Vinci™ Robotic Surgical System (Intuitive Surgical, Inc., Sunny Vale, California), was introduced in 1997 in Brussels. The first clinical robot-assisted surgical procedure was performed in March 1997 by Drs. Cadiere and Himpens, using the da Vinci™ System for a cholecystectomy. The first robot-assisted cardiac procedure was performed in May 1998, and the first closed chest coronary artery bypass graft was performed with this instrumentation in June of that year. In 1998 the Zeus® Robotic Surgical System (Computer Motion, Santa Barbara, California) was introduced. The first robot-assisted operation in the US was performed using this system pre-FDA clearance in 1998. Following randomized clinical trials, the da Vinci™ Surgical System was FDA approved for surgery in the US, July 12, 2000. Clinical trials are presently underway with the Zeus® system in preparation for FDA approval.

The da Vinci™ and Zeus® robotic systems are conceptually similar, with a surgeon console or workstation connected by cables to a system of robotic arms to manipulate the laparoscope and surgical instruments. The da Vinci™ console places two independent monitors in front of the surgeon’s eyes, providing true three-dimensional vision and the perception of immersion of the surgeon into the surgical field. The Zeus® work station is more open, giving the surgeon a more direct external view of the operating room environment, and the surgeon views a traditional monitor with a computer simulated three-dimensional system using special glasses. Both systems have adjustable motion scaling allowing the surgeon to control the precision of instrument movement. Both have electronic filtering to remove tremor and wrists near the instrument tips to provide added flexibility and dexterity. The da Vinci™ wrists have 6 degrees of freedom with both pitch and yaw to give 360-degree rotation of the wrist. The latest version of Zeus® has 5 degrees of freedom to give either pitch or yaw deflection, and full 360-degree wrist rotation is performed by torquing the shaft of the instrument. The Zeus® system has three separate working arms (one camera arm and two robotic arms for the surgeon’s instruments), which are independently fixed to the operating room table. The da Vinci™ System has a patient side tower with a robotic arm for the camera and two robotic working arms. With these robotic systems, the surgeon has complete control of the camera operation and the surgical instruments, with a precision that cannot be duplicated by human hands with traditional instrumentation. The latest version of the da Vinci™ comes with a fourth robotic arm and software that allows the surgeon to assist himself or herself without releasing the master controls.

Fulfilling the Promise? Since FDA approval for the da Vinci™ System, thousands of robot-assisted laparoscopic digestive and urological procedures have been performed in the US. Most traditional laparoscopic procedures are now being performed by robot-assisted technique. Clearly, robots are not essential for basic laparoscopic procedures. Robotic precision is most useful for extremely fine dissection, for precise suturing techniques, and for dissection and suturing in awkward or narrow anatomical locations. Horgan and Melvin demonstrated the robot to be more precise for the dissection of the cardiomyotomy for Heller procedures. At their respective institutions, 80 Heller myotomies were performed with no esophageal mucosal perforations. The reported incidence of mucosal perforations with traditional MIS ranges between 5% and 15% [10]. Several groups, including Dr. Horgan’s and our own, are using the robot to suture the gastrojejunostomy for gastric bypass procedures, finding that suturing in this awkward location is far easier and more precise than with traditional MIS. Few studies comparing the results of robot-assisted and traditional MIS have been reported thus far, but many will be forthcoming now that the feasibility and safety have been established.

The most salient value of robotics is the enabling function of this technology and its potential to allow surgeons to perform complex tasks which exceed their abilities with traditional MIS. Laparoscopic radical prostatectomy was first reported in 1992 [11]. However, relatively few centers have embraced this procedure because very few urologists have the laparoscopic experience to feel comfortable with the technique, especially with suturing the urethral anastomosis. In some centers, however, urological surgeons with no previous laparoscopic experience [12] are now performing robot-assisted laparoscopic radical prostatectomy. Cardiac surgeons typically have no background experience with laparoscopic techniques, but many centers internationally are now performing robot-assisted closed chest coronary artery bypass and mitral valve procedures, some experiencing two day lengths of stay [13-16].  Laparoscopic aortofemoral bypass surgery was first reported by Dion in 1993 [17]. Dion and Gracia [18], and others [19,20] have reported substantial series, but very few surgeons are currently performing laparoscopic aortic surgery. Although many vascular surgeons perform basic MIS, almost none have experience with laparoscopic suturing. In June 2001, the first robot-assisted fully laparoscopic aortofemoral bypass was performed in our community hospital in Richmond, Virginia by Dr. Barklie Zimmerman, a vascular surgeon with no advanced laparoscopic experience. Assisted patient-side by an advanced laparoscopic surgeon, Zimmerman’s first clinical experience with laparoscopic suturing was a successful aortofemoral bypass. Enabled by the robotic technology, he was able to complete the complicated aortic anastomosis very comfortably. The patient was discharged two days after surgery and played golf fourteen days after his aortic surgery.

Most of the limiting characteristics of traditional MIS have been solved or improved by the current robotic platforms. The laparoscopic skills of virtually any surgeon are improved by robotic instrumentation. For some surgeons, complex suturing techniques are routine, but the majority of surgeons and surgical specialists find these techniques challenging. A mere two years after FDA approval of the da Vinci™ Robotic Surgical System, however, the scope of MIS has been significantly expanded for several surgical specialties. As the instruments become smaller and more refined, similar advances in image-guided neurosurgery and intrauterine fetal surgery are anticipated. Evaluations are currently underway using the robot-assisted surgery for pancreatic surgery [21], biliary reconstruction, and pediatric surgery [22]. The promise of closed chest cardiac surgery and of hybrid endovascular and closed CABG procedures appears to be nearing fruition.

Robotic technology is still in its infancy. With current robotic instruments the surgeon lacks proprioception and haptic feedback. One truly remote, transoceanic cholecystectomy was performed by Gagner and Marescaux in 2001 with the Zeus® system at the cost of one million dollars. However, the problem of latency between the surgeon’s movements and the response of distant instruments remains to be solved before remote operations can be done routinely. These current limitations of robotics will be resolved as the technology matures. Subsequent robotic systems will doubtless bear little resemblance to the present instrumentation. By way of comparison, however, the evolution of this technology should be compared to laparoscopic surgery circa 1988. As the robotic platforms and instruments evolve, the interposition of computers between surgeons and new, very smart instruments will continue to expand the horizons of minimally invasive surgery. Institutions will have to develop responsible credentialing criteria for the new technology [23]. The economic feasibility of these new technologies will remain a source of controversy, and evidence-based outcome evaluation will be of crucial importance.

Address reprint requests to: William E. Kelley, Jr, MD, FACS, 8921 Three Chopt Rd Ste 300, Richmond, VA 23229, Telephone: 804 285 9416, Fax: 804 285 0840, E-mail: kelleyjr@richmond.infi.net, Web site: www.richmondsurgicalonline.com

Dr Kelley is in private practice with The Richmond Surgical Group in Richmond, Virginia. He serves on the clinical faculty at the Medical College of Virginia, and is Director of General Surgery for the Minimally Invasive Surgery Center of Virginia. Dr Kelley served for ten years as Virginia State Chairman for the Society of American Gastrointestinal Endoscopic Surgeons and is on the Editorial Board of JSLS, Journal of the Society of Laparoendoscopic Surgeons. He has contributed to over a hundred papers and presentations and has written textbook chapters on laparoscopic colon and spleen surgery and image guided breast surgery. Dr Kelley currently serves on the Board of Trustees for the Society of Laparoendoscopic Surgeons (SLS) and is Chair of the SLS Antireflux Surgery Committee.

References

1.    Semm K, Operative Manual for Endoscopic Abdominal Surgery. Chicago: Yearbook Medical Publishers; 1987.

2.    Ballantyne GH. The pitfalls of laparoscopic surgery: challenges for robotic surgery. Surg Laparosc Endosc. 2002;12:1-5.

3.    Berci G, Shore JM, et al. The evaluation of a new peritoneoscope as a diagnostic aid for surgeons. Ann Surg. 1973;178:37-44.

4.    Cuschieri A. Value of laparoscopy in hepatobiliary disease. Br J Surg. 1974;61:318-319.

5.    Warshaw AC, Dteper JE, Shipley WU. Laparoscopy in staging and planning therapy for pancreatic cancer. Am J Surg. 1986;151:16.

6.    Reynolds W. The first laparoscopic cholecystectomy. JSLS. 2001;5:89-94.

7.    Dubois F, Icard P, et al. Celioscopic cholecystectomy: a preliminary report of 36 cases. Ann Surg. 1990;211:60-62.

8.    Talamini MA. Surgery in the 21st century. Ann Surg. 2001;234:8-9.

9.    Satava, RM. Surgical Robotics: the early chronicles, a personal perspective. Surg Laparosc Endosc. 2002;12:6-16.

10.    Horgan S, Melvin S. Robot assisted Heller myotomy. Presented at Digestive Disease Week, SSAT; May 2002; San Francisco, CA.

11.    Schuessler WW, Davoussi LR, Clayman RV. Laparoscopic radical prostatectomy: initial case report. J Urol. 1992;147:246.

12.    Binder J, Bendtas W, Wolfram M, et al. Remote-controlled laparoscopic radical prostatectomy using the da Vinci surgical system. Ospedali D’Idtalia Chirurgia. 2001;7:432-436.

13.    Fegler JE, Nifong LW, Chitwood WR. The evolution of and early experience with robot-assisted mitral valve surgery. Surg Laparosc Endosc. 2002;1:58-63.

14.    Loulmet D, Carpentier ASA, d’Attelis N, et al. Endoscopic coronary artery bypass grafting with the aid of computer-assisted instruments. J Thorac Cardiovasc Surg. 1999;48:4-10.

15.    Mohr FW, Falk V, Diegeler A, et al. Computer-enhanced coronary bypass surgery. J Thorac Cardiovasc Surg. 1999;117:1212-1214.

16.    Vigano M, Mauro R, Temistocle R. Robot-assisted cardiac surgery: preliminary experience of one center. Ospedali D’Italia Chururgia. 2001;7:418-421.

17.    Dion YM, Katkhouda N, Rouleau C, et al. Laparoscopy-assisted aortobifemoral bypass for occlusive disease. Can J Surg. 1993;3:425-9.

18.    Dion YM, Gracia CR. A new technique for laparoscopic aortobifemoral grafting in occlusive aortoiliac disease. J Vasc Surg. 1997;26:685-692.

19.    Barbera L, Geier B, Demen M, Mumme A. Clinical experiences with 43 cases of laparoscopic reconstruction in aortoiliac occlusive diseases: analysis of morbidity, effectiveness, and treatment results. Zentralbl Chir. 2001;126:134-137.

20.    Kline RG, D’Angelo AJ, Chen MH, et al. Laparoscopically assisted abdominal aortic aneurysm repair: first 20 cases. J Vasc Surg. 1998;27:81-87.

21.    Broeders IAMJ. Robotics in vascular surgery: what to expect? Ospedali D’Italia Chirurgia. 2001;7:422-5.

22.    Hollands C. Robotics in pediatric surgery. Presented at: SAGES postgraduate course: Robot-assisted laparoscopic surgery; March 2002; New York, NY.

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