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DOI: 10.2478/v10206-011-0016-5 Review Annals of Fundeni Hospital, volume 16, no. 3 - 4, July - December 2011 Dan Setlacec Center of General Surgery and Liver Transplantation, Fundeni Clinical Institute, Bucharest, Romania The introduction of laparoscopic surgery in the early nineties of the last century represented a revolution in surgery. Better cosmetic and functional results, quicker professional and social reintegration of the patient was immediately obvious. More than this, the laparoscopy allowed the design and implementation of another revolution in surgery that means the robotic surgery. Robots were around for quite a while but lately they are becoming more and more important, to the point that a prestigious scientific journal named the 21-st century "Century of Robots". The word comes from the Czech "robota", equivalent of "work" which shows form the beginning the intention of the "inventors" to put those machines to work. Today robots are used to perform highly specific, highly precise, and dangerous tasks in industry and research previously not possible with a human work force. Like this, precious human resources can be spared and better used. Even more, for the machines the Latin percept "errare humanum est" (which in surgery is never accepted) does not apply. So, following the example of industry and of some military applications, the medicine tried to follow. From their inception, surgical robots have been envisioned to extend the capabilities of human surgeons beyond the limits of conventional laparoscopy. The history of robotics in surgery begins with the Puma 560, a six degree of freedom robot manipulator used in 1985 by Kwoh et al to perform neurosurgical biopsies with greater precision. (Fig. 1) Three years later, Davies et al performed a transurethral resection of the prostate using the Puma 560. This system eventually led to the Figure 1 - Puma 560 Robotic Manipulator Address for correspondence: Irinel Popescu, MD, FACS, FEBS, Professor of Surgery, "Dan Setlacec" Center for General Surgery and Liver Transplantation, Fundeni Clinical Institute, Sos. Fundeni, 258, 022328, Bucharest, Romania, e-mail: email@example.com Figure 2 - The surgical robot, Robodoc for hip replacement surgery development of PROBOT, a robot designed specifically for transurethral resection of the prostate. Resection coordinates are programmed after initial visualization, targeting, and operative planning based on transrectal ultrasound. In 1992 Integrated Surgical Supplies Ltd. of Sacramento, CA, was developing ROBODOC, a robotic system designed to machine the femur with greater precision in hip replacement surgeries. ROBODOC reams the femoral shaft for prosthetic devices to precise, preprogrammed specifications and recognizes points of reference by targets placed during preoperative mapping. ROBODOC was the first surgical robot approved by the FDA (Fig. 2). In addition to Prodoc, ROBODOC and the systems mentioned above several other robotic systems have been commercially developed and approved by the FDA for general surgical use. These include the AESOP system (Computer Motion Inc., Santa Barbara, CA), a voice-activated robotic endoscope, and the comprehensive master-slave surgical robotic systems, Da Vinci (Intuitive Surgical Inc., Mountain View, CA) and Zeus (Computer Motion Inc., Santa Barbara, CA) (Fig. 3). In March 7, 2003, Computer Motion and Intuitive Surgical merged into a single company. This was done to combine their efforts in developing robotic surgical systems, to increase the effectiveness of such technology. Soon after merging, the ZEUS was phased out in favor of the Da Vinci system from Intuitive Surgical. Before everything, we have to say that the surgical robot is mainly a very sophisticated computer, in which the "informatics" component surpasses by far the "mechanical" one. Strange enough, the Da Vinci system is not really a "robot", in the strict meaning of this word, because it cannot do anything alone. It is merely a different way in which surgeons perform miniinvasive surgery: comfortably seated, with a tridimensional view and better magnification, using versatile instruments that can perfectly work in the narrow spaces of the pelvis or the gastroesophageal area. All these features are quite enough to define a major progress in surgery, if not another "revolution". But the current state of surgical robotics is clearly just the beginning of what it is supposed to come. Figure 3 - Zeus Robotics System, the surgical device (left) that is controlled by a surgeon sitting at a remote console (right) Because, definitely, the real goal of the robotic project is to reach the stage when the robots will operate themselves and not being just a mere extension of the human hand. That moment for sure will come, sooner or later, determined mainly by the increasing performance of the informatics system and a perfect combination with imagery (the later will "tell" the robot where the lesion is, how much to cut and how to reconstruct). Coming back to the present, we have to notice that robotics is gaining momentum, perhaps not so quick like laparoscopy (the high cost is also an important limiting factor!), but definitely as a method "to stay". Robotic radical prostatectomy has clearly become the standard operation, so that any other approach would be inferior in terms of the benefits of the patient. Other procedures (radical rectal resection, radical hysterectomy, achalasia, Nissen fundoplicaton, etc) will probably follow. The evolution of surgical robots along with the recent developments in information technology has opened up new horizons in teaching field. With the improvements in the techniques used in the generation of multimedia virtual reality and the progressive reduction in the costs of technological processes, it has been possible to develop dedicated systems for the teaching of anatomy, as well as the physiology and pathology in a virtual environment. Training new surgeons is expensive, regardless of whether the machine is in a dedicated laboratory setting or if it is shared in a clinical setting. Thanks to the robot simulators that integrate appropriate software, it is possible to simulate delicate operations to allow the surgeon to correct any eventual technique errors and thereby gain self-confidence. This is one of the most revolutionary features fundamental to robotic surgery and it holds significant relevance for the way in which new surgeons can be trained at the daVinci console. The surgeon is no longer in direct contact with the patient and the interface is operated by a computer. For the junior surgeons, the robot system is a valid aid in learning the fundamentals of a surgical procedure thus helping them gain confidence with surgical maneuvers and allowing the acquisition of the manual dexterity The Center of General Surgery and Liver Transplantation "Dan Setlacec" was always a frontrunner in introducing new techniques and technologies in Romanian surgery. Therefore looks more than natural that the first organized program of robotic surgery was set up here. Everything started in 2008 due to the acquisition of a robotic system Da Vinci S by the Ministry of Education special for our Center (Fig. 4). This proved to be a fateful decision, since in the first year of use, we already performed 153 operations. The first one was a cholecystectomy performed by the Greek surgeon Konstantin Konstantinidis, who became a good friend and was a nice guest during the last World Congress of Robotic Surgery (Athens 2010). Figure 4 - da Vinci S surgical system The second procedure was a left lateral sectionectomy (former "segmentectomy") that was performed by the author of this article. Both procedures were successfully done and the postoperative course of the two patients was uneventful. Three teams are performing currently robotic surgery in our Center and the area of procedures is rather large, covering many areas of general surgery: esophageal, gastric, hepatic, splenic, pancreatic, colonic, rectal, genital, thymus, adrenals, etc. We present our experience of robotic surgery between January 2008 and August 2011 in Table 1. The results are getting better and better and the duration of the operation becomes shorter. The advantages for both patient and surgeon are the above mentioned. To give a particular example, in rectal surgery the oncologic Table 1 Diagnosis Surgical procedure No. of cases n=484 1 39 4 16 15 2 1 3 18 2 1 2 2 1 1 20 1 11 3 15 9 48 16 18 4 2 3 11 14 1 2 8 17 6 1 1 Operative Time Mean (Range) min 100 151 (70-240) 600 265 (140-400) 187 (180-200) 220 60 90 (45-120) 178 (60-200) 200 240 200 60 60 137 (120-180) 320 220 (180-300) 120 240 184 (120-240) 225 (150-300) 180 (180) 142 (90-200) 110 (100-120) 135 (120-150) 109 (60-200) 165 (60-240) 109 (60-200) 240 60 135 (120-150) 180 (180) 135 (120-150) 120 120 Postoperatory stay Mean (Range) days 4 6 (3-11) 10 12 (6-20) 13 (9-17) 8 4 4 7 (2-10) 4 7 13 38 4 11 (4-19) 7 11 (7-20) 5 14 5 (6-13) 14 (7-49) 10,5 (10-11) 7,5 (3-10) 5,5 (4-7) 6,5 (6-7) 4 (3-6_ 5 (2-10) 6 (3-12) 10 5 13 (11-15) 7 (5-9) 18 (7-29) 6 2 Gallstones Achalasia Esophageal carcinoma Gastric carcinoma Benign gastric tumors Obesity GERD Obstr jaundice Chronic pancreatitis Insulinoma Pancreatic abcess Serous hepatic Cyst Hepatic neoplasm Right colon carcinoma Benign colonic polyp Left colon carcinoma Sigmoid carcinoma Rectal carcinoma Inferior rectal carcinoma Splenic lymphoma Splenic hydatic cyst Splenic serous cyst Splenic serous cyst Hereditary microspherocitosis Idiopathic Thrombocytopenic Purpura Portal cavernoma Autoimmune hemolytic anemia Liver cirrhosis with splenomegaly Adrenal tumors Adrenal cyst Thymic cyst Cholecystectomy Myotomy+ Dor fundoplication Transthoracic esophagectomy Subtotal gastrectomy Total gastrectomy Gastroenteroanastomosis Polipectomy through gastrotomy Sleeve gastrectomy Nissen fundoplication Toupet fundoplication Cholecistectomy + choledocoduodenoanastomosis Distal pancreatectomy Enucleo-resection Drainage Cyst fenestration Hepatic segmentectomy Right hepatectomy Right hemicolectomy Polypectomy through colotomy Left hemicolectomy Segmentary sigmoidian resection Low anterior resection Abdominoperineal resection Splenectomy Partial resection of spleen Partial resection of spleen Splenectomy Subtotal splenectomy Splenectomy Hassab op Splenectomy Splenectomy Right adrenalectomy Left adrenalectomy Adrenal cyst ablation Thymectomy Diagnosis Surgical procedure Myasthenia gravis Uterine fibroma Uterine tumors Cervix tumors Ovarian benign tumor Endometriosis Goitre Thymectomy Total hysterectomy with bilateral anexectomy Radical hysterectomy with pelvic and paraaortic lymphadenectomy Radical hysterectomy with pelvic lymphadenectomy Anterior pelvic exenteration Total pelvic exenteration Radical hysterectomy with ureteral reimplantation Unilateral adnexectomy Ablation Total thyroidectomy with open and robotic thoracic approach No. of cases n=484 53 11 19 60 5 3 3 2 5 4 Operative Time Mean (Range) min 123 (40-200) 160 (120-180) 236 (150-400) 256 (150-480) 230 (210-250) 260 (240-320) 240 (210-250) 60 240 (240) Postoperatory stay Mean (Range) days 3 (2-18) 7 (6-8) 3 (3-35) 13 (5-29) 8 (5-14) 9 (8-18) 12 (9-19) 3 6,5 (5-8) principles are totally respected, but the nerve preservation is better with all the favorable consequences on genital and urinary function. Robotic surgery has already proven itself to be of great value, particularly in areas inaccessible to conventional laparoscopic procedures. It remains to be seen, however, if robotic systems will replace conventional laparoscopic instruments in less technically demanding procedures. In any case, robotic technology is set to revolutionize surgery by improving and expanding laparoscopic procedures, advancing surgical technology, and bringing surgery into the digital age. Furthermore, it has the potential to expand surgical treatment modalities beyond the limits of human ability.
Annals of Fundeni Hospital – de Gruyter
Published: Dec 1, 2011
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