Robot-assisted laparoscopic surgery: Just another toy?

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Apollo Medicine 2012 SeptemberVolume 9, Number 3; pp. 239e241 Review Article

Robot-assisted laparoscopic surgery: Just another toy?

Bhaskar Pal*

Senior*Tel.:ReceivCopyrihttp://d

ABSTRACT

One of the most significant developments in medical technology in the past decade is the advent of Robot-assistedlaparoscopic surgery. Laparoscopic surgery has distinct advantages over conventional open surgery, and mostgynecological procedures can now be performed by the laparoscopic route. However, the popularity and acceptanceof laparoscopic surgery is far from universal, mainly due to the technical difficulties in the procedure. Laparoscopicsurgery requires training and skill, and has a long learning curve. Robot-assisted surgery may help overcome some ofthese problems.

Copyright © 2012, Indraprastha Medical Corporation Ltd. All rights reserved.

Keywords: Robot-assisted laparoscopic surgery, Gynecological procedures

INTRODUCTION

Laparoscopic surgery in gynecology: currentstatus

Laparoscopic surgery, in comparison to traditional opensurgery, offers a less invasive option in most gynecologicalprocedures. Hysterectomies, myomectomies, removal ofadnexal masses, tubal anastomosis, radical hysterectomiesand lymphadenectomies can all be performed by the laparo-scopic route. Compared to open surgery, the hospital stay issignificantly shorter, recovery is quicker and mean bloodloss is less with laparoscopic surgery with comparablecomplication rates and operating times in experiencedhands. Current evidence suggests that laparoscopic hyster-ectomy is preferable to abdominal hysterectomy for benignconditions.1

However, the majority of hysterectomies worldwide arestill performed by the abdominal route. In the first half ofthe last decade, about 80% of hysterectomies were per-formed by the abdominal route in one state of the USA.2

The lack of popularity of laparoscopic surgery amongmajority of gynecologists has two several reasons. Firstly,laparoscopic surgery has a steep and extended learning

Consultant Gynecologist, Apollo Gleneagles Hospital, 58, Canal Circþ91 9831298236, email: [email protected]: 22.6.2012; Accepted: 29.6.2012; Available online: 5.7.2012ght � 2012, Indraprastha Medical Corporation Ltd. All rights reservedx.doi.org/10.1016/j.apme.2012.06.001

curve. Secondly, many advanced gynecological surgeriesby the laparoscopic route are technically challenging. Thesein turn are due to several factors:d Using long instruments through a fixed entry point

accentuates small movements and tremors.d The limited range of movement of instruments requires

ergonomically challenging positions at times.d An unstable camera, especially when held by an inexpe-

rienced assistant, hampers visualization.d The two-dimensional optics causes loss of depth

perception.d Long procedures, due to these reasons, add to fatigue.

ROBOTS: WHAT AND WHY?

The robotic system does away with several of the disadvan-tages of laparoscopic surgery. The da Vinci Robotic system(Intuitive Surgical, Sunnyvale, CA, USA) was approved bythe US FDA for use in gynecology in 2005. It consists ofthree components: the surgeon’s console, which directsthe movements of the robotic arms, the stack, and thepatient-side cart, which in the latest system has four arms.After port placements and docking the patient-side cart,

ular Road, Kolkata 700054, India.

.

240 Apollo Medicine 2012 September; Vol. 9, No. 3 Pal

the surgeon sits at the console and operates. The camerasystem is controlled by the surgeon through foot pedalsand arm movements. At the console, the surgeon controlsthe robotic arms and the EndoWrist instruments withnatural hand and wrist motions that mimic movements per-formed in open surgery. The foot pedals control swappingin and out the third robotic arm, moving and focusing thecamera, and controlling monopolar and bipolar currentsconnected to the EndoWrist instruments.

ADVANTAGES OF THE DA VINCI ROBOTICSYSTEM

d At the console, the surgeon has a binocular three-dimen-sional view of the pelvis in High Definition. This givesa perception of depth.

d The camera remains still, and is controlled by thesurgeon’s foot pedal when necessary.

d The console has armrests and, adjustable height andeyepieces. These reduce surgeon fatigue.

d Motion scaling converts very large movements of thesurgeon’s hand to veryfinemovements of the instruments.

d At the console, the surgeon controls the robotic arms andthe EndoWrist instruments with natural hand and wristmotions that mimic movements performed in opensurgery.

d The EndoWrist instruments are designed with sevendegrees of motion, one more than the human hand.

d The three operating arms are controlled by the surgeonwho can switch between instruments using the controlpedal. On disengaging one arm to use another, the disen-gaged arm remains stationary but maintains tension onthe grasped tissue.

d Changing operating instruments can be done quickly, asthe new instrument returns to the same place as theremoved one.

d The energy sources are controlled by the surgeonthrough foot pedals.

d Additional ports can be introduced to use alternativeenergy sources or for morcellation.

d Uterine manipulator inserted vaginally adds to the easeof operating.

DISADVANTAGES OF THE DA VINCI ROBOTICSYSTEM

d Cost is the biggest disadvantage. This includes the initialcost, the cost of instruments and the cost of maintenance.

d Setting up and docking takes time, but gets quicker withuse.

d There is a loss of tactile sensation, hence the amount offorce to be used comes with experience.

d There is a learning curve, although it is shorter than lapa-roscopic surgery.

d Staff needs to be trained in set up of the system andcleaning of instruments.

APPLICATIONS IN GYNECOLOGY

The da Vinci Robotic system has been used to performhysterectomies, myomectomies, tubal anastomosis, sacro-colpopexy, advanced endometriosis including rectovaginaldisease, radical hysterectomy with lymphadenectomy andother procedures. In centers practicing robotic surgery, therates of abdominal surgeries have reduced; more patientscan be offered the benefit of minimally invasive surgery.

TRAINING

Laparoscopic surgery, as discussed earlier, has a long andextended learning curve. In comparison, robotic surgeryhas a shorter learning curve and can be taught to surgeonswho are not well-versed in advanced laparoscopy. This willlead to more robotic surgeons than experienced laparo-scopic surgeons, as it easier and quicker to train residentsin Robotic surgery than conventional laparoscopic surgery.One study demonstrated a more rapid learning curve, forboth experienced and inexperienced surgeons, in the perfor-mance of drills using a robotic system.3 Another studydemonstrated that laparoscopic drills were performedmore quickly using a robotic system compared to tradi-tional laparoscopy and that novice surgeons on the robotperformed as quickly, and in some cases more quickly,than expert surgeons with traditional laparoscopy.4

EVIDENCE

In some countries the da Vinci Robotic surgery has beenwidely and rapidly adopted. There are evidences ofdeclining rates of abdominal as well as laparoscopic hyster-ectomies with a proportionate rise in robotic surgery.5

However, there is a paucity of good quality data address-ing the superiority of robotic surgery over laparoscopicsurgery. Most of the data consist of retrospective caseseries, some with historical controls and several review arti-cles summarizing these data. There are hardly any random-ized trial, and most case series use historical controls ofabdominal surgery. There are some studies in which thecontrols are laparoscopic surgeries performed by experts.None of the studies established a cost-benefit with roboticsurgery. It is also too early to get long-term data, especially

Robot-assisted laparoscopic surgery Review Article 241

in gynecological oncology. A recent meta-analysis ofobservational studies has looked at the evidence in differentgynecological procedures.6 While robotic surgery has thesame advantages over conventional open surgery as lapa-roscopy, ie quicker recovery, less mean blood loss, shorterhospital stay, the operating times are usually longer, withsimilar complication rates. In the few studies comparinglaparoscopic with robotic surgery, there is less mean bloodloss and fewer conversions to open surgery in the lattergroup. This reinforces the point that complex problemswhere laparoscopic surgery may be long and tiring for thesurgeon, robot-assisted surgery will have a better chanceof success. In all the studies, the operating time with roboticsurgery is longer, but it tends to decrease as the number ofcases goes up. Robotic surgery is also significantly moreexpensive than laparoscopic surgery.

CONCLUSION

Robotic surgery has great potential to revolutionaries thepractice of minimal access surgery, making it possible formore gynecologists to learn and perform minimal accesssurgery, although cost is a big deterrent especially ina developing country. However, any new innovation comeswith great potential for harm, and Robotic surgery is noexception. With proper training and skill, along with judi-cious patient selection, robot-assisted laparoscopic surgerycan be highly advantageous. However, in the past, manyinnovations had become dangerous tools in the hands ofuntrained or poorly trained operators. Long-term safetyand cost-effectiveness data are still awaited for roboticsurgery, and till then it should be used judiciously. Accord-ing to ACOG7 “further studies as well as additional cost-effective analyses need to be done to critically evaluatethe role of robotic surgery in gynecology before it is adop-

ted as common practice in managing gynecologic diseases.”However, in private healthcare patients often demand thebest, and Robot-assisted surgery will continue to be usedmore frequently by doctors for whom it is the morecomfortable option.

CONFLICTS OF INTEREST

The author has none to declare.

REFERENCES

1. Nieboer TE, Johnson N, Lethaby A, et al. Surgical approach tohysterectomy for benign gynaecological disease. CochraneDatabase Syst Rev 2009;(3). http://dx.doi.org/10.1002/14651858.CD003677.pub4. Art. No.: CD003677.

2. Tu FF, Beaumont JL, Senapati S, Gordon TEJ. Route of hyster-ectomy influence and teaching hospital status. Obstet Gynecol.2009;114:73e78.

3. Prasad SM, Maniar HS, Soper NJ, et al. The effect of roboticassistance on learning curves for basic laparoscopic skills.Am J Surg. 2002;183:702e707.

4. Sarle R, Tewari A, Shrivastava A, et al. Surgical robotics andlaparoscopic training drills. J Endourol. 2004;18:63e66.

5. Peplinski R. Past, Present and Future of the Da Vinci Robot, in2nd UK Robotic Urology Course. London, UK: Guy’sHospital; 2006.

6. Weinberg L, Rao S, Escobar PF. Robotic surgery in gynae-cology: an updated systematic review. Obtet Gynecol Int.2011;2011:852061.

7. ACOG technology assessment in obstetrics and gynecologyNo. 6: robot-assisted surgery. Obstet Gynecol. 2009;114:1153e1155.

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