‘The Terminator’ was an awesome movie; ‘Data’ was a favorite robot on the cult series Star Trek; and the baby boomers will never forget the Robot shouting “Danger, Will Robinson!” on the series Lost in Space. When we recall our favorite robots, however, we don’t see them wearing surgical scrubs and wielding a scalpel. Instead, when we think of surgery, we imagine a knife-wielding, masked surgeon, creating railroad track incisions across knees and abdomens. Now, with ever-increasing frequency, robots and surgeons come together to perform procedures through tiny incisions during robotic surgery.
What Is Robotic Surgery?
Robotic surgery can be summed up in just three words: minimally invasive surgery. Instead of the classic railroad track incisions which have historically been carved into operative sites, with related incisions through the layers of the human body below, the work of surgery is achieved through millimeters-long incisions. No, the surgeon is not poking a finger down through a tiny incision, blindly repairing and plucking out innards. He is using an automated set of mechanized arms and foot pedals, attached to a digital console, connected to a driver’s seat.
Technically, robotic surgery is more accurately called robot-assisted surgery; the physician still does all of the thinking, problem-solving and commandeering of the plethora of devices and programs built into the machine. The surgeon is not alone, however; additional video screens allow members of the surgical team to view exactly what the surgeon is looking at, and to respond almost instantaneously to dynamic operative needs.
Robotic surgery goes beyond fluoroscopic and ultrasound guided invasive techniques. Robot-assisted surgery comes closer to the robots in the movies and our minds with four arms, 2 feet, 3-D vision, and artificial intelligence.
The Da Vinci
Firmly entrenched in hospital operating rooms is the representative for robotic surgery, the da Vinci Si Works automaton. The da Vinci is composed of two communicating sections, the tower, and the console. The tower assumes the traditional position of the hunched surgeon postured over the patient and supports the robot’s four arms. The console is the command center where the surgeon sits and operates the robot’s controls while looking through a monitor that provides high definition 3-D vision; foot pedals provide additional manipulation and control.
The Arms and Wrists
The robot has four arms attached to a freestanding cart-like body. One arm holds a laparoscopic camera; an antenna-like stick with a camera attached to it is guided through a few millimeters-wide incision and travels around the patient’s insides to provide a three-dimensional, real-time view of what the surgeon is looking at. The other three arms are controlled by the surgeon’ s fingers inserted into rings and manipulating all the imaginable surgical instruments with the same motions as if those instruments were handheld.
Precision and maneuverability are created by the EndoWrists; the flexible mechanical extensions that mimic the motions of the human wrist.
This robot has two stereoscopic, three-dimensional high definition lens systems that can magnify the surgical field up to 10 times, eliminating the need for the surgeon to wear microscope laden lenses against his/her eyes. Accuracy and depth perception are enhanced with crisp, sharp images. The rest of the surgical team get their own eyes; monitors are available for others to view the same thing the surgeon is looking at. Image referencing allows the surgeon to visualize the diagnostic images alongside a surgical field of view, eliminating the need for CT scans or ultrasonography.
The Console and Feet
The console is the captain’s chair of the so-called surgical spaceship; the surgeon can sit in an ergonomically designed and maneuverable chair to operate hand and foot controls. The surgeon is also able to look through the robot’s eyes while at the console. The surgeon manipulates instruments with scalable precision by way of hand controls, computerized inputs, and foot pedals. Foot pedals allow the surgeon to operate with multiple energy modalities and manipulate the positioning of components used in robotic surgery.
Big brother robotic technology is watching the surgeon, the equipment and the surgery. The surgeon’s forehead must be seated inside the face port viewer; if the surgeon is not in the correct position, the robot will lock and remain so until the surgeon’s head is repositioned correctly. An emergency stop button, however, allows the surgeon to use impose and shut down the robotic device in case the robot assumes a mind and a will of its own. Microchips within each instrument allow the robot to log each use and to monitor the integrity and need to replace each instrument.
Telecommuting and Geometry
Robotic surgery can also be done by tele-collaboration through a voice-activated control option. This, however, is the exception rather than the rule, as it is not the current intention of robotic surgery. Geometry is at the heart of robotic movements. Phrases related to the mathematical discipline are assigned to the 7° of motion derived from the human wrist and arm capabilities:
If the surgeon is the director, then the orchestra is the robot, and the procedure is the symphony:
The robot (the orchestra), directed by the surgeon (the conductor), creates the overture harmony, melody and finale (symphony) in a far better synchronization of effort than the surgeon could perform solo.
Advantages of Robotic Surgery
Robotic surgery got its beginnings by virtue of the fact that necessity is the mother of all invention. Traditional laparoscopic surgery has certain limitations that add to the complexity and risk of certain procedures. Two-dimensional imaging, limited range of motion with instruments and limited positioning of the surgeon are eliminated with the use of surgical automatons. The development of robotic surgery brought revolutionary changes for physicians in training by virtue of shared viewing and team operations.
Robotic surgery has vastly improved patient outcomes, especially when compared to traditional operative techniques and procedures:
The days of the long railroad track incisions, and all the slow and difficult requirements to heal such incisions, are numbered. Robotic surgery makes operative procedures easier for trained surgeons to perform, and makes improved patient outcomes, in terms of complications, a reality.
The Future of Robotic Surgery
Robotic surgery is here to stay. Not only does Medicare/TRICARE and third-party payers approve of the use of robotic surgery, but these devices are also driving patients into the operating rooms. Robotic surgery is big business, and so the competition to improve upon robotic devices is fierce. At the heart of the free market system is competition, and competition creates quality.
Da Vinci was the first robotic-assisted surgery device approved for general laparoscopic surgery in the year 2000; it is now in its fourth generation of design, which means that more types of procedures are being performed by robotic surgery. There are now more than a dozen competitors that are tinkering in their shops to create a bigger and better robot.
The SenHance device has features that allow the surgeon to assess the stiffness of tissue and improve on the control of movement. Other competitors are developing robotics that are used with CT guided procedures, and another hopeful is developing a 2-pound device that operates entirely inside the body through a single incision.
Artificial intelligence (AI) is hot on the trail of robotic surgery innovation. AI speaks not only to precision and control, but to the planning, troubleshooting, and real-time analytics. Imagine a surgeon running into a problem during a procedure; a short video or algorithm could automatically pop up to help the surgeon successfully navigate through the unexpected condition. Remote proctoring of physicians in training using AI enabled robots is also on the drawing board.
Robotic surgery is the 21st century’s answer to minimal surgery techniques. Although there are many different types of robotic devices, the da Vinci Si Works machine serves as perhaps the most common choice of hospitals and other surgical providers.
The robot comes with a brain, multiple eyes, four arms, two feet, and a driver’s seat.
There is no need, however, to conjure up terrifying visions of The Terminator or the Robot from Lost In Space, standing over your opened belly and rummaging around your innards with mechanical pliers while you play there helplessly anesthetized— robotic surgery is actually a physician-guided servant.