- Email: [email protected]
Overview—Current Clinical and Preclinical Use of Robotics for Surgery
Overview—Current Clinical and Preclinical Use of Robotics for Surgery Mark A. Talamini, M.D. The first device for abdominal and thoracic surgery was approved for use by the FDA on June 16, 1999. This ushered in a new and exciting age of surgery, with potential limited only by surgeons’ dreams and engineers’ capabilities. An early challenge is that of definitions. A robot is defined as “a machine that resembles a human and does mechanical, routine tasks on command” or “any machine or mechanical device that operates automatically with humanlike skill” (Webster’s Universal College Dictionary). Although the machines developed for surgery currently do not resemble humans on a large scale, two important aspects of the system resemble human capabilities— three-dimensional visualization and wristlike movements of the end effectors. However, they do not execute preprogrammed independent actions. Rather, these devices are designed to enhance the capabilities of surgeons. The implication that these devices act independently, created by using the term robot, may cause appropriate apprehension among patients and the public. A more precise term might be computer-enhanced telemanipulator. However, the simpler and more exciting term robot is already in common usage. Robotic technology has been used to great advantage in nonmedical applications for a long time. Maintenance of the nuclear arsenal, production of automobiles, and manipulations in space all benefit from the field of robotics. Surgery has been slower to take advantage of this technology for obvious reasons. But engineers and forward-thinking surgeons have been thinking, dreaming, and working toward the introduction of robotic technology into the world of surgery. Dr. Russ Taylor, while working at IBM and after joining the Johns Hopkins faculty, was performing such work, in consultation with a variety of surgeons. One potential disadvantage of robotic devices is the lack of feedback regarding the amount of pressure they may be exerting on tissues. In a
series of experiments, using a robotic device designed by Dr. Taylor’s team, we sought to determine whether a robotic device would be better or worse than human force during organ retraction.1 To accomplish this, we modified a laparoscopic retraction device by adding pressure sensors. We then compared the pressures generated during porcine laparoscopic operations in which the robotic device applied retraction pressure or a human did so. We found that the robot applied a more consistent retraction pressure and less overall retraction pressure than did the human. Thus this seems to be an instance where a robotic device can perform a boring, repetitive task in a more consistent, and perhaps safer, manner. Retraction pressures applied during open and laparoscopic operations on humans have not been measured, so we really do not know what an appropriate pressure is for retracting an organ such as the liver. We are working to accomplish such studies now. This is an example of preclinical work that will likely contribute to the evolution of surgical robotic devices. One of the first devices used clinically in human surgery was the “Robo-doc” system for orthopedic surgery.2 Its intention was to improve on a task performed by hand by surgeons. The task, in this instance, was bone drilling to fit a hip prosthesis, to create a more ideal fit between prosthesis and bone. This system continues to be used clinically. Experience has rapidly accumulated since the approval by the FDA of the daVinci Surgical System (Intuitive Surgical, Inc., Sunnyvale, CA). We recently reported a combined series of clinical cases from four institutions at the SAGES meeting in New York. In that presentation, four institutions (East Carolina University, Johns Hopkins University, Ohio State University, and the University of Illinois at Chicago) reported on a prospective analysis of 211 robotically assisted procedures performed between June 2000 and June 2001 using the daVinci system. The procedures
Presented at the SSAT/SAGES Joint Symposium, San Francisco, California, May 22, 2002. From the Department of Surgery (M.A.T.), Johns Hopkins University School of Medicine, Baltimore, Maryland. Correspondence: Mark A. Talamini, M.D., Department of Surgery, Johns Hopkins School of Medicine, 600 N. Wolfe Street, Blalock 665, Baltimore, MD, 21287.
쑖 2003 The Society for Surgery of the Alimentary Tract, Inc. Published by Elsevier Inc.
1091-255X/03/$—see front matter doi:10.1016/S 1 0 9 1 - 2 5 5 X ( 0 3 ) 0 0 0 3 1 - 3
479
480
Journal of Gastrointestinal Surgery
Talamini
undertaken included antireflux surgery (n ⫽ 69), cholecystectomy (n ⫽ 36), Heller myotomy (n ⫽ 26), bowel resection (n ⫽ 17), donor nephrectomy (n ⫽ 15), left internal mammary artery mobilization (n ⫽ 14), gastric bypass (n ⫽ 7), splenectomy (n ⫽ 7), adrenalectomy (n ⫽ 6), exploratory laparoscopy (n ⫽ 3), pyloroplasty (n ⫽ 4), gastrojejunostomy (n ⫽ 2), distal pancreatectomy (n ⫽ 1), duodenal polypectomy (n ⫽ 1), esophagectomy (n ⫽ 1), gastric mass resection (n ⫽ 1), and lysis of adhesions (n ⫽ 1). In this series of patients, the average operating room time was 188 minutes (range 45 to 387 minutes, standard deviation [SD] ⫽ 83), surgical time was 143 minutes (range 35 to 462 minutes, SD ⫽ 63), and the actual robot use time was 90 minutes (range 12 to 235 minutes, SD ⫽ 47). The median length of stay was 1 day (range 0 to 37 days). There were eight technical complications (4%) during these procedures—five minor (4 hook cautery dislodgement and 1 slipped robotic trocar) and three major (system malfunctions, 2 of which required conversion to standard laparoscopy). In all cases, technical problems caused only delay, without apparent altered outcome. Medical/surgical complications occurred in nine patients (4%). Six (3%) were considered major, including one death unrelated to the robotic procedure. The group concluded that the results of robotic-assisted surgery compared favorably with those of commonly reported conventional laparoscopy with respect to mortality, complications, and length of stay. A number of other interesting reports are also beginning to appear in the literature. A series of 146 cases from a single institution in which the daVinci system was used was reported by Cadiere et al.3 The authors opine that the daVinci system is most effective for fine manipulations in a small space. The two most popular systems (daVinci Surgical System and ZEUS Robotic Surgical System; Computer Motion, Goleta, CA) were compared in an animal
study reported by Sung and Gill.4 They concluded that the operative times and the learning curve were shorter with the daVinci system, although both systems were effective. A group from France reported an initial experience with 25 robotic laparoscopic cases, all cholecystectomies.5 They also concluded that computer-assisted surgery is feasible and safe, with operative times and recovery comparable to laparoscopic cholecystectomy. The group from Ohio State compared computer-assisted and laparoscopic antireflux operations. Although the operating times were longer for the robotic group, there were no other differences seen in the perioperative course or the clinical outcomes.6 The world of surgery is rapidly changing. The current generation of robotic systems for general surgical applications is only a beginning, but it is an impressive beginning. Issues with these systems certainly exist, such as the additional time necessary and the cumbersome nature of the machinery. As surgeons and engineers continue to work together, future systems will evolve into tools that are beyond our current imagination. REFERENCES 1. Poulose BK, Kutka MF, Mendoza-Sagaon M, et al. Human vs robotic organ retraction during laparoscopic Nissen fundoplication. Surg Endosc 1999;13:461–465. 2. Taylor RH, Joskowicz L, Williamson B, et al. Computerintegrated revision total hip replacement surgery: Concept and preliminary results. Med Image Anal 1999;3:301–319. 3. Cadiere GB, Himpens J, Germay O, et al. Feasibility of robotic laparoscopic surgery: 146 cases. World J Surg 2001;25: 1467–1477. 4. Sung GT, Gill IS. Robotic laparoscopic surgery: A comparison of the daVinci and Zeus per Medline systems. Urology 2001;58:893–898. 5. Marescaux J, Smith MK, Folscher D, et al. Telerobotic laparoscopic cholecystectomy: Initial clinical experience with 25 patients. Ann Surg 2001;234:1–7. 6. Melvin WS, Needleman BJ, Krause KR, Schneider C, Ellison EC. Computer-enhanced vs. standard laparoscopic anti reflux surgery. J GASTROINTEST SURG 2002;6:11–16.
series of experiments, using a robotic device designed by Dr. Taylor’s team, we sought to determine whether a robotic device would be better or worse than human force during organ retraction.1 To accomplish this, we modified a laparoscopic retraction device by adding pressure sensors. We then compared the pressures generated during porcine laparoscopic operations in which the robotic device applied retraction pressure or a human did so. We found that the robot applied a more consistent retraction pressure and less overall retraction pressure than did the human. Thus this seems to be an instance where a robotic device can perform a boring, repetitive task in a more consistent, and perhaps safer, manner. Retraction pressures applied during open and laparoscopic operations on humans have not been measured, so we really do not know what an appropriate pressure is for retracting an organ such as the liver. We are working to accomplish such studies now. This is an example of preclinical work that will likely contribute to the evolution of surgical robotic devices. One of the first devices used clinically in human surgery was the “Robo-doc” system for orthopedic surgery.2 Its intention was to improve on a task performed by hand by surgeons. The task, in this instance, was bone drilling to fit a hip prosthesis, to create a more ideal fit between prosthesis and bone. This system continues to be used clinically. Experience has rapidly accumulated since the approval by the FDA of the daVinci Surgical System (Intuitive Surgical, Inc., Sunnyvale, CA). We recently reported a combined series of clinical cases from four institutions at the SAGES meeting in New York. In that presentation, four institutions (East Carolina University, Johns Hopkins University, Ohio State University, and the University of Illinois at Chicago) reported on a prospective analysis of 211 robotically assisted procedures performed between June 2000 and June 2001 using the daVinci system. The procedures
Presented at the SSAT/SAGES Joint Symposium, San Francisco, California, May 22, 2002. From the Department of Surgery (M.A.T.), Johns Hopkins University School of Medicine, Baltimore, Maryland. Correspondence: Mark A. Talamini, M.D., Department of Surgery, Johns Hopkins School of Medicine, 600 N. Wolfe Street, Blalock 665, Baltimore, MD, 21287.
쑖 2003 The Society for Surgery of the Alimentary Tract, Inc. Published by Elsevier Inc.
1091-255X/03/$—see front matter doi:10.1016/S 1 0 9 1 - 2 5 5 X ( 0 3 ) 0 0 0 3 1 - 3
479
480
Journal of Gastrointestinal Surgery
Talamini
undertaken included antireflux surgery (n ⫽ 69), cholecystectomy (n ⫽ 36), Heller myotomy (n ⫽ 26), bowel resection (n ⫽ 17), donor nephrectomy (n ⫽ 15), left internal mammary artery mobilization (n ⫽ 14), gastric bypass (n ⫽ 7), splenectomy (n ⫽ 7), adrenalectomy (n ⫽ 6), exploratory laparoscopy (n ⫽ 3), pyloroplasty (n ⫽ 4), gastrojejunostomy (n ⫽ 2), distal pancreatectomy (n ⫽ 1), duodenal polypectomy (n ⫽ 1), esophagectomy (n ⫽ 1), gastric mass resection (n ⫽ 1), and lysis of adhesions (n ⫽ 1). In this series of patients, the average operating room time was 188 minutes (range 45 to 387 minutes, standard deviation [SD] ⫽ 83), surgical time was 143 minutes (range 35 to 462 minutes, SD ⫽ 63), and the actual robot use time was 90 minutes (range 12 to 235 minutes, SD ⫽ 47). The median length of stay was 1 day (range 0 to 37 days). There were eight technical complications (4%) during these procedures—five minor (4 hook cautery dislodgement and 1 slipped robotic trocar) and three major (system malfunctions, 2 of which required conversion to standard laparoscopy). In all cases, technical problems caused only delay, without apparent altered outcome. Medical/surgical complications occurred in nine patients (4%). Six (3%) were considered major, including one death unrelated to the robotic procedure. The group concluded that the results of robotic-assisted surgery compared favorably with those of commonly reported conventional laparoscopy with respect to mortality, complications, and length of stay. A number of other interesting reports are also beginning to appear in the literature. A series of 146 cases from a single institution in which the daVinci system was used was reported by Cadiere et al.3 The authors opine that the daVinci system is most effective for fine manipulations in a small space. The two most popular systems (daVinci Surgical System and ZEUS Robotic Surgical System; Computer Motion, Goleta, CA) were compared in an animal
study reported by Sung and Gill.4 They concluded that the operative times and the learning curve were shorter with the daVinci system, although both systems were effective. A group from France reported an initial experience with 25 robotic laparoscopic cases, all cholecystectomies.5 They also concluded that computer-assisted surgery is feasible and safe, with operative times and recovery comparable to laparoscopic cholecystectomy. The group from Ohio State compared computer-assisted and laparoscopic antireflux operations. Although the operating times were longer for the robotic group, there were no other differences seen in the perioperative course or the clinical outcomes.6 The world of surgery is rapidly changing. The current generation of robotic systems for general surgical applications is only a beginning, but it is an impressive beginning. Issues with these systems certainly exist, such as the additional time necessary and the cumbersome nature of the machinery. As surgeons and engineers continue to work together, future systems will evolve into tools that are beyond our current imagination. REFERENCES 1. Poulose BK, Kutka MF, Mendoza-Sagaon M, et al. Human vs robotic organ retraction during laparoscopic Nissen fundoplication. Surg Endosc 1999;13:461–465. 2. Taylor RH, Joskowicz L, Williamson B, et al. Computerintegrated revision total hip replacement surgery: Concept and preliminary results. Med Image Anal 1999;3:301–319. 3. Cadiere GB, Himpens J, Germay O, et al. Feasibility of robotic laparoscopic surgery: 146 cases. World J Surg 2001;25: 1467–1477. 4. Sung GT, Gill IS. Robotic laparoscopic surgery: A comparison of the daVinci and Zeus per Medline systems. Urology 2001;58:893–898. 5. Marescaux J, Smith MK, Folscher D, et al. Telerobotic laparoscopic cholecystectomy: Initial clinical experience with 25 patients. Ann Surg 2001;234:1–7. 6. Melvin WS, Needleman BJ, Krause KR, Schneider C, Ellison EC. Computer-enhanced vs. standard laparoscopic anti reflux surgery. J GASTROINTEST SURG 2002;6:11–16.