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Feasibility of robot-assisted laparoscopic cholecystectomy
International Congress Series 1230 (2001) 160 – 165
Feasibility of robot-assisted laparoscopic cholecystectomy J.P. Ruurda*, I.A.M.J. Broeders Department of Surgery, University Medical Centre Utrecht, HP G04-228, P.O. Box 85500, 3508 GA Utrecht, The Netherlands
Abstract To enhance the surgeon’s dexterity in laparoscopic surgery, robotic telemanipulation systems have recently been introduced into the operating theatre. Feasibility of robot-assisted surgery was evaluated in this study during 20 laparoscopic cholecystectomies. The procedures were performed with the Da Vinci1 robotic telemanipulation system (Intuitive Surgical). System set-up time, complications, technical problems and OR-time were recorded. The surgeon succeeded in completing the cholecystectomy laparoscopically in 19 out of 20 cases. Robot-related technical problems did occur in a low number of cases. This did not result in complications or harmful situations to the patient. OR time in robot-assisted cases exceeded the time needed for conventional laparoscopic cholecystectomy, mainly caused by time-loss during set-up. D 2001 Elsevier Science B.V. All rights reserved. Keywords: Robotics; Minimal invasive; Surgery; Telemanipulation; Laparoscopy
1. Introduction The widespread introduction of laparoscopic techniques is considered one of the most prominent changes in surgical technology in the last decade of the 20th century. Many open surgical procedures, such as cholecystectomy, inguinal hernia repair and oesophageal reflux surgery, have been reduced to minimally invasive interventions. This has resulted in a shorter postoperative stay, less pain, better cosmetics and faster return to daily activity. Where laparoscopic surgery offers the patient clear benefits, it introduces disadvantages to the surgeon as compared to open surgery. In open procedures, the surgeon’s flexibility *
Corresponding author. Tel.: +31-30-250-9111; fax: +31-30-250-5459. E-mail address: [email protected] (J.P. Ruurda).
0531-5131/01/$ – see front matter D 2001 Elsevier Science B.V. All rights reserved. PII: S 0 5 3 1 - 5 1 3 1 ( 0 1 ) 0 0 0 4 0 - 1
J.P. Ruurda, I.A.M.J. Broeders / International Congress Series 1230 (2001) 160–165
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in positioning his body, elbow, wrist and fingers offers an unlimited range of motion. The operative field can be approached from various directions, and the surgeon controls his actions by visual and tactile feedback. During endoscopic surgical interventions, surgeons face the problem of working with long instruments through fixed entrypoints. The instruments can be pivoted with a limited incline in the horizontal and vertical plane around the point of trocar insertion. They can be moved in and out the patient’s body or rotated around the longitudinal axis. When including the specific task of the end-effector of the instrument, the surgeon’s actions are therefore limited to five degrees of freedom (DOF) (Fig. 1). With such limitations, basic surgical manoeuvres like suturing demand highly developed technical skills. Another limitation of laparoscopic surgery is the unnatural hand – eye coordination, caused by the movement of the end-effector of instruments in opposite direction of the action provoking this movement. This reversed instrument action is inevitably linked to working through access-ports and thus introducing a momentum to the surgeon’s movements. This momentum also causes variability in the angular displacement performed outside the body and the resulting effect inside. When for example most of the instrument is inside, a small movement at the outside can cause major displacement of the instrument tip at the inside of the body (Fig. 2). The hand –eye coordination is further deteriorated by the loss of the eye –hands– target axis, compromising normal oculovestibular input [1]. While looking at a two-dimensional screen, surgeons are also limited by the loss of visual perception of depth. An additional problem in the visualisation process is the need for a human assistant in order to hold the endoscope. This causes discomfort, because the
Fig. 1. Degrees of freedom in standard laparoscopy: (1) rotation around longitudinal axis, (2) pivoting in the horizontal, (3) vertical plane, and (4) in/out the patient’s body, (5) the specific task of the end-effector.
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J.P. Ruurda, I.A.M.J. Broeders / International Congress Series 1230 (2001) 160–165
Fig. 2. The trocar opening introduces a momentum causing reversed instrument action. Thereby it causes variability in the angular displacement performed outside the patient’s body and the resulting effect inside.
field of view is no longer under the surgeons’ direct control. Orientation errors or unstable camera control may further compromise the smoothness of the operation. Although many abdominal operations can be performed laparoscopically at this moment in time, standard performance of complex minimally invasive surgery stays in the hands of a limited number of experts, due to the limitations mentioned. In order to cope with these limitations, researchers started developing new tools for laparoscopic surgery, starting with camera guidance systems such as the Aesop1, Tiska1, Fips1 and Endoassist1 [2 –6]. This finally resulted in the development of robotic telemanipulation systems. Within this concept, the surgeon controls a manipulation system, while working from a master console. Taking the surgeon away from the operation table allows positioning a computer between the surgeon’s hands and the end-effectors of the instruments, using computing power to support the surgeon’s dexterity. A range of advantages and possibilities is hereby offered to the surgeon as compared to laparoscopic surgery. Not only the restoration of the limited dexterity laparoscopy goes accompanied with, but also in the field of visualisation, ergonomics, tremor eradication and scaling opportunities. Various types of procedures have already been performed with the robotic systems currently available. Although there are still some aspects that need to be modified, the robotic telemanipulation systems may increase the number and range of minimal invasive procedures in the next couple of years by allowing surgeons to perform more complex surgical procedures in a safe and efficient manner. To demonstrate and evaluate technical feasibility of robotic assisted laparoscopy, 20 laparoscopic cholecystectomies were performed.
J.P. Ruurda, I.A.M.J. Broeders / International Congress Series 1230 (2001) 160–165
163
2. Methods Twenty robot-assisted laparoscopic cholecystectomies were performed with the Da Vinci system (Intuitive Surgical, Mountain View, CA) (Fig. 3). The system consists of a masterconsole, where the surgeon is seated, looking at a three-dimensional binocular display of the operative field. The controllers are placed underneath the display. A three-armed robot cart is placed at the operation table. The middle arm carries the two-channel optical system. The two independent video images are transmitted to the binocular display to be merged, where they provide a true 3D image of the operative field. The camera is controlled by the Navigator2 system, which enables the surgeon to pick up and move the camera with the master controllers, after pressing a foot pedal. During the camera movement, the slave instruments stay in position. Another foot pedal freezes the instruments, which allows repositioning the controllers and forearms to an ergonomically favourable position. The control devices have a configuration similar to regular surgical instruments. The surgeon’s motions are transposed to the tips of tiny instruments, where the Endowrist1 system provides the surgeon with seven degrees of freedom inside the patient’s body. This system allows the surgeon to perform his manipulations intuitively hereby mimicking the natural movements of open surgery. The intuitive control of motions is enhanced in the Da Vinci system by the restoration of the eye –hand – target axis, due to the integration of both visual
Fig. 3. The Da Vinci1 surgical telemanipulation system.
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J.P. Ruurda, I.A.M.J. Broeders / International Congress Series 1230 (2001) 160–165
system and manipulators in the master-console. For safety reasons, the system goes directly in stand-by modus, when the surgeon moves away from the 3D binoculars. Three surgeons were trained to perform the laparoscopic cholecystectomies with the Da Vinci system. In every case, one of these surgeons controlled the master manipulator; one of the others assisted at the OR tableside. The tableside surgeon introduced the trocars. Two trocars were introduced for the robot instrument-arms, one for the robot camera-arm, and one additional trocar for an instrument to retract the gallbladder. The tableside surgeon assisted in retracting the gallbladder and changing the instruments. The console surgeon performed the actual cholecystectomy. Set-up time, OR-time, complications and technical problems were recorded.
3. Results In 19 cases (19/20; 95%), the cholecystectomy was completed laparoscopically. There was one conversion to an open procedure, caused by the surgeons’ incapability to manipulate the gallbladder, due to severe cholecystitis. There were no robot-related complications. Technical problems did occur in three cases, the main problem being breakdown of disposable instruments. Total OR-time was longer compared to conventional laparoscopic cholecystectomies. The main cause for the time-loss was rather found in set-up time than in effective surgery time. The time needed to install the robotic system exceeded the time needed for set-up in open surgery. Set-up time decreased with experience of the OR-crew. Effective dissection time was shorter in the robot-assisted cases. The time-loss caused by set-up time could not be compensated for by this shorter dissection time.
4. Discussion Technical feasibility of robot-assisted laparoscopic cholecystectomy was repeatedly demonstrated. No significant problems were noted during these procedures. The system showed to enhance the surgeon’s dexterity and visualisation possibilities, providing intuitive control of the instruments. Although surgical robotics is considered to be in an early phase of development, the opportunities robotic telemanipulators offer are already distinct. They provide endoscopic surgeons with a dexterity incomparable to the way they used to perform laparoscopic surgery. An important robot-related issue requiring further attention is the reliability and assortment of disposable instruments. Since robotic systems have only recently been introduced into the surgical theatre, the companies are still in an early phase of instrument development. With more surgeons in various disciplines working with the systems, the demand for new reliable instruments will rise notably. As well as a broader assortment of instruments, a decrease in instrument and camera size has to be achieved. The issue of time-loss seems eventually to be overcome. Although set-up is still timeconsuming, the time-loss could partly be corrected by the shorter dissection time in the robot-assisted laparoscopic cholecystectomy cases. Set-up times will further decrease with
J.P. Ruurda, I.A.M.J. Broeders / International Congress Series 1230 (2001) 160–165
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increasing experience. A solution to the time-loss might be the future designation of dedicated OR’s, where the robotic systems may be integrated in the surgeon’s workplace, attached to the ceiling or operating table. Another possible solution is the efficient usage of changing times between procedures. One of the major points of criticism towards robotic systems is the lack of tactile feedback. This is only partly compensated for by the 3D visual feedback. Adding tactile feedback is one of the most challenging topics in the development of these systems in the upcoming years. In the laparoscopic cholecystectomy, the lack of tactile feedback was not experienced as disturbing, but in procedures demanding higher technical skills its presence will be vital. Costs are also a considerable factor. The robotic hardware is expensive, and so are the disposable accessories. Widespread use of the robotic systems may reduce these costs to reasonable numbers. For the moment, the advantages robotic systems offer during laparoscopic cholecystectomy do not outweigh the rise in costs they go accompanied with. System ergonomics remain an issue. A serious reduction in size and weight would sincerely improve the ability to implement systems in the OR. Not only will they have to become easier to install with regard to the ideal placement for a procedure, but also in combination with anaesthesia and X-ray equipment.
5. Conclusion Technical feasibility of robot-assisted laparoscopic cholecystectomy was repeatedly demonstrated. No significant problems were noted during these procedures. The system showed to enhance the surgeon’s dexterity and visualisation possibilities, providing intuitive control of the instruments. Still, there remain some important robot-related issues requiring further attention. If these problems are solved, these systems can be implemented in both routine and complex endoscopic surgery.
References [1] R.M. Satava, S.R. Ellis, Human interface technology, An essential tool for the modern surgeon, Surg. Endosc. 8 (1994) 817 – 820. [2] J.M. Sackier, Y. Wang, Robotically assisted laparoscopic surgery, From concept to development, Surg. Endosc. 8 (1994) 63 – 66. [3] L.K. Jacobs, V. Shayani, J.M. Sackier, Determination of the learning curve of the AESOP robot, Surg. Endosc. 11 (1997) 54 – 55. [4] M.O. Schurr, A. Arezzo, B. Neisius, H. Rininsland, H.U. Hilzinger, J. Dorn, K. Roth, G.F. Buess, Trocar and instrument positioning system TISKA, An assist device for endoscopic solo surgery, Surg. Endosc. 13 (1999) 528 – 531. [5] G.F. Buess, A. Arezzo, M.O. Schurr, F. Ulmer, H. Fisher, L. Gumb, T. Testa, C. Nobman, A new remotecontrolled endoscope positioning system for endoscopic solo surgery, The FIPS endoarm [see comments], Surg. Endosc. 14 (2000) 395 – 399. [6] M. Schurr, A. Arezzo, G.F. Buess, Robotics and systems technology for advanced endoscopic procedures: experiences in general surgery, Eur. J. Cardiothoracic Surg. 16 (Suppl. 2) (1999) S97 – S105.
Feasibility of robot-assisted laparoscopic cholecystectomy J.P. Ruurda*, I.A.M.J. Broeders Department of Surgery, University Medical Centre Utrecht, HP G04-228, P.O. Box 85500, 3508 GA Utrecht, The Netherlands
Abstract To enhance the surgeon’s dexterity in laparoscopic surgery, robotic telemanipulation systems have recently been introduced into the operating theatre. Feasibility of robot-assisted surgery was evaluated in this study during 20 laparoscopic cholecystectomies. The procedures were performed with the Da Vinci1 robotic telemanipulation system (Intuitive Surgical). System set-up time, complications, technical problems and OR-time were recorded. The surgeon succeeded in completing the cholecystectomy laparoscopically in 19 out of 20 cases. Robot-related technical problems did occur in a low number of cases. This did not result in complications or harmful situations to the patient. OR time in robot-assisted cases exceeded the time needed for conventional laparoscopic cholecystectomy, mainly caused by time-loss during set-up. D 2001 Elsevier Science B.V. All rights reserved. Keywords: Robotics; Minimal invasive; Surgery; Telemanipulation; Laparoscopy
1. Introduction The widespread introduction of laparoscopic techniques is considered one of the most prominent changes in surgical technology in the last decade of the 20th century. Many open surgical procedures, such as cholecystectomy, inguinal hernia repair and oesophageal reflux surgery, have been reduced to minimally invasive interventions. This has resulted in a shorter postoperative stay, less pain, better cosmetics and faster return to daily activity. Where laparoscopic surgery offers the patient clear benefits, it introduces disadvantages to the surgeon as compared to open surgery. In open procedures, the surgeon’s flexibility *
Corresponding author. Tel.: +31-30-250-9111; fax: +31-30-250-5459. E-mail address: [email protected] (J.P. Ruurda).
0531-5131/01/$ – see front matter D 2001 Elsevier Science B.V. All rights reserved. PII: S 0 5 3 1 - 5 1 3 1 ( 0 1 ) 0 0 0 4 0 - 1
J.P. Ruurda, I.A.M.J. Broeders / International Congress Series 1230 (2001) 160–165
161
in positioning his body, elbow, wrist and fingers offers an unlimited range of motion. The operative field can be approached from various directions, and the surgeon controls his actions by visual and tactile feedback. During endoscopic surgical interventions, surgeons face the problem of working with long instruments through fixed entrypoints. The instruments can be pivoted with a limited incline in the horizontal and vertical plane around the point of trocar insertion. They can be moved in and out the patient’s body or rotated around the longitudinal axis. When including the specific task of the end-effector of the instrument, the surgeon’s actions are therefore limited to five degrees of freedom (DOF) (Fig. 1). With such limitations, basic surgical manoeuvres like suturing demand highly developed technical skills. Another limitation of laparoscopic surgery is the unnatural hand – eye coordination, caused by the movement of the end-effector of instruments in opposite direction of the action provoking this movement. This reversed instrument action is inevitably linked to working through access-ports and thus introducing a momentum to the surgeon’s movements. This momentum also causes variability in the angular displacement performed outside the body and the resulting effect inside. When for example most of the instrument is inside, a small movement at the outside can cause major displacement of the instrument tip at the inside of the body (Fig. 2). The hand –eye coordination is further deteriorated by the loss of the eye –hands– target axis, compromising normal oculovestibular input [1]. While looking at a two-dimensional screen, surgeons are also limited by the loss of visual perception of depth. An additional problem in the visualisation process is the need for a human assistant in order to hold the endoscope. This causes discomfort, because the
Fig. 1. Degrees of freedom in standard laparoscopy: (1) rotation around longitudinal axis, (2) pivoting in the horizontal, (3) vertical plane, and (4) in/out the patient’s body, (5) the specific task of the end-effector.
162
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Fig. 2. The trocar opening introduces a momentum causing reversed instrument action. Thereby it causes variability in the angular displacement performed outside the patient’s body and the resulting effect inside.
field of view is no longer under the surgeons’ direct control. Orientation errors or unstable camera control may further compromise the smoothness of the operation. Although many abdominal operations can be performed laparoscopically at this moment in time, standard performance of complex minimally invasive surgery stays in the hands of a limited number of experts, due to the limitations mentioned. In order to cope with these limitations, researchers started developing new tools for laparoscopic surgery, starting with camera guidance systems such as the Aesop1, Tiska1, Fips1 and Endoassist1 [2 –6]. This finally resulted in the development of robotic telemanipulation systems. Within this concept, the surgeon controls a manipulation system, while working from a master console. Taking the surgeon away from the operation table allows positioning a computer between the surgeon’s hands and the end-effectors of the instruments, using computing power to support the surgeon’s dexterity. A range of advantages and possibilities is hereby offered to the surgeon as compared to laparoscopic surgery. Not only the restoration of the limited dexterity laparoscopy goes accompanied with, but also in the field of visualisation, ergonomics, tremor eradication and scaling opportunities. Various types of procedures have already been performed with the robotic systems currently available. Although there are still some aspects that need to be modified, the robotic telemanipulation systems may increase the number and range of minimal invasive procedures in the next couple of years by allowing surgeons to perform more complex surgical procedures in a safe and efficient manner. To demonstrate and evaluate technical feasibility of robotic assisted laparoscopy, 20 laparoscopic cholecystectomies were performed.
J.P. Ruurda, I.A.M.J. Broeders / International Congress Series 1230 (2001) 160–165
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2. Methods Twenty robot-assisted laparoscopic cholecystectomies were performed with the Da Vinci system (Intuitive Surgical, Mountain View, CA) (Fig. 3). The system consists of a masterconsole, where the surgeon is seated, looking at a three-dimensional binocular display of the operative field. The controllers are placed underneath the display. A three-armed robot cart is placed at the operation table. The middle arm carries the two-channel optical system. The two independent video images are transmitted to the binocular display to be merged, where they provide a true 3D image of the operative field. The camera is controlled by the Navigator2 system, which enables the surgeon to pick up and move the camera with the master controllers, after pressing a foot pedal. During the camera movement, the slave instruments stay in position. Another foot pedal freezes the instruments, which allows repositioning the controllers and forearms to an ergonomically favourable position. The control devices have a configuration similar to regular surgical instruments. The surgeon’s motions are transposed to the tips of tiny instruments, where the Endowrist1 system provides the surgeon with seven degrees of freedom inside the patient’s body. This system allows the surgeon to perform his manipulations intuitively hereby mimicking the natural movements of open surgery. The intuitive control of motions is enhanced in the Da Vinci system by the restoration of the eye –hand – target axis, due to the integration of both visual
Fig. 3. The Da Vinci1 surgical telemanipulation system.
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J.P. Ruurda, I.A.M.J. Broeders / International Congress Series 1230 (2001) 160–165
system and manipulators in the master-console. For safety reasons, the system goes directly in stand-by modus, when the surgeon moves away from the 3D binoculars. Three surgeons were trained to perform the laparoscopic cholecystectomies with the Da Vinci system. In every case, one of these surgeons controlled the master manipulator; one of the others assisted at the OR tableside. The tableside surgeon introduced the trocars. Two trocars were introduced for the robot instrument-arms, one for the robot camera-arm, and one additional trocar for an instrument to retract the gallbladder. The tableside surgeon assisted in retracting the gallbladder and changing the instruments. The console surgeon performed the actual cholecystectomy. Set-up time, OR-time, complications and technical problems were recorded.
3. Results In 19 cases (19/20; 95%), the cholecystectomy was completed laparoscopically. There was one conversion to an open procedure, caused by the surgeons’ incapability to manipulate the gallbladder, due to severe cholecystitis. There were no robot-related complications. Technical problems did occur in three cases, the main problem being breakdown of disposable instruments. Total OR-time was longer compared to conventional laparoscopic cholecystectomies. The main cause for the time-loss was rather found in set-up time than in effective surgery time. The time needed to install the robotic system exceeded the time needed for set-up in open surgery. Set-up time decreased with experience of the OR-crew. Effective dissection time was shorter in the robot-assisted cases. The time-loss caused by set-up time could not be compensated for by this shorter dissection time.
4. Discussion Technical feasibility of robot-assisted laparoscopic cholecystectomy was repeatedly demonstrated. No significant problems were noted during these procedures. The system showed to enhance the surgeon’s dexterity and visualisation possibilities, providing intuitive control of the instruments. Although surgical robotics is considered to be in an early phase of development, the opportunities robotic telemanipulators offer are already distinct. They provide endoscopic surgeons with a dexterity incomparable to the way they used to perform laparoscopic surgery. An important robot-related issue requiring further attention is the reliability and assortment of disposable instruments. Since robotic systems have only recently been introduced into the surgical theatre, the companies are still in an early phase of instrument development. With more surgeons in various disciplines working with the systems, the demand for new reliable instruments will rise notably. As well as a broader assortment of instruments, a decrease in instrument and camera size has to be achieved. The issue of time-loss seems eventually to be overcome. Although set-up is still timeconsuming, the time-loss could partly be corrected by the shorter dissection time in the robot-assisted laparoscopic cholecystectomy cases. Set-up times will further decrease with
J.P. Ruurda, I.A.M.J. Broeders / International Congress Series 1230 (2001) 160–165
165
increasing experience. A solution to the time-loss might be the future designation of dedicated OR’s, where the robotic systems may be integrated in the surgeon’s workplace, attached to the ceiling or operating table. Another possible solution is the efficient usage of changing times between procedures. One of the major points of criticism towards robotic systems is the lack of tactile feedback. This is only partly compensated for by the 3D visual feedback. Adding tactile feedback is one of the most challenging topics in the development of these systems in the upcoming years. In the laparoscopic cholecystectomy, the lack of tactile feedback was not experienced as disturbing, but in procedures demanding higher technical skills its presence will be vital. Costs are also a considerable factor. The robotic hardware is expensive, and so are the disposable accessories. Widespread use of the robotic systems may reduce these costs to reasonable numbers. For the moment, the advantages robotic systems offer during laparoscopic cholecystectomy do not outweigh the rise in costs they go accompanied with. System ergonomics remain an issue. A serious reduction in size and weight would sincerely improve the ability to implement systems in the OR. Not only will they have to become easier to install with regard to the ideal placement for a procedure, but also in combination with anaesthesia and X-ray equipment.
5. Conclusion Technical feasibility of robot-assisted laparoscopic cholecystectomy was repeatedly demonstrated. No significant problems were noted during these procedures. The system showed to enhance the surgeon’s dexterity and visualisation possibilities, providing intuitive control of the instruments. Still, there remain some important robot-related issues requiring further attention. If these problems are solved, these systems can be implemented in both routine and complex endoscopic surgery.
References [1] R.M. Satava, S.R. Ellis, Human interface technology, An essential tool for the modern surgeon, Surg. Endosc. 8 (1994) 817 – 820. [2] J.M. Sackier, Y. Wang, Robotically assisted laparoscopic surgery, From concept to development, Surg. Endosc. 8 (1994) 63 – 66. [3] L.K. Jacobs, V. Shayani, J.M. Sackier, Determination of the learning curve of the AESOP robot, Surg. Endosc. 11 (1997) 54 – 55. [4] M.O. Schurr, A. Arezzo, B. Neisius, H. Rininsland, H.U. Hilzinger, J. Dorn, K. Roth, G.F. Buess, Trocar and instrument positioning system TISKA, An assist device for endoscopic solo surgery, Surg. Endosc. 13 (1999) 528 – 531. [5] G.F. Buess, A. Arezzo, M.O. Schurr, F. Ulmer, H. Fisher, L. Gumb, T. Testa, C. Nobman, A new remotecontrolled endoscope positioning system for endoscopic solo surgery, The FIPS endoarm [see comments], Surg. Endosc. 14 (2000) 395 – 399. [6] M. Schurr, A. Arezzo, G.F. Buess, Robotics and systems technology for advanced endoscopic procedures: experiences in general surgery, Eur. J. Cardiothoracic Surg. 16 (Suppl. 2) (1999) S97 – S105.