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Robotics, Technology, and the Future of Surgery

Robotics, Technology, and the Future of Surgery EDITORIAL Michael S. Kavic, MD Editor-in-Chief Technology and the creative use of the newly developed These characteristics are hindrances to the diffusion of solid state, charge coupled device (CCD) cameras, minimally invasive surgery, but they are not insurmount- laparoscopes, clip appliers, and energy sources enabled able problems. Rather, they are challenges. Disposable the laparoscopic revolution of the 1990s. And, without instruments can be made in a reusable format with sig- doubt, evolving technology will sustain the development nificant cost savings. Personnel can be cross-trained and of minimally invasive surgery. But the technology that used more efficiently. Three-dimensional laparoscopic fueled the laparoscopic revolution is aged and now hin- cameras are available and can be further refined. These ders further advances in the field. remedies, however, are only “quick fixes.” A more com- plete solution is needed for a comprehensive transition In particular, several characteristics inherent to laparo- to minimally invasive surgery and, ultimately, for the scopic surgery have slowed its more general diffusion evolution to noninvasive, image-guided therapies. into the surgical mainstream. These characteristics include: Operating rooms (OR) designed for open surgery of the mid-20th century have not been easily adapted to a 1) The requirement of laparoscopic surgery for highly laparoscopic environment. Frequently floors of rooms trained personnel to maintain instruments and to used for laparoscopic surgery are cluttered with cables assist during an operative procedure; and wires connecting video monitors, light generators, and energy sources. Tubes linking suction devices to 2) Expensive instrumentation (particularly disposables); suction-aspirators and oxygen lines add to the confusion. 3) Poor ergonomic design of laparoscopic instruments; Towers containing insufflation devices, video recorders, fiberoptic light sources, and monitors are cumbersome 4) Two-dimensional video representation of the and difficult to move. More wires and tubes connect the real-world, 3-dimensional operative field; patient to anesthetic delivery machines and monitoring 5) Work environment not conducive to operator devices. The technologies have been “added on” rather comfort: than “integrated into” the operating theater, and the “added on” look is very evident in a typical operating a. poor monitor placement room. b. inefficient operating instruments sited remote The human arm and hand, although a marvelous device from the operative site for the performance of specific tasks, is another unit that has not adapted well to laparoscopic surgery. The arm- c. limited ability to steer rigid laparoscopic hand unit has 7 degrees of freedom (DOF) that allows instruments the hand to be precisely manipulated in 3-dimensional 6) Lack of haptic (touch) sense; space. However, during minimally invasive surgery, can- nula diameter forbids ingress of a hand into the opera- 7) Surgeon dependence upon a camera operator for tive field and laparoscopic instruments must be substi- visualization of the operative field. tuted for it. First generation laparoscopic instruments have been a poor substitute for the hand and are limited Department of Surgery, Northeastern Ohio Universities College of Medicine, in range to 4 degrees of freedom. The first 2 degrees of Rootstown, Ohio. Department of Surgery, University of Pittsburgh School of freedom concern rotation of the laparoscopic instrument Medicine, Pittsburgh, Pennsylvania. around the point of insertion in the X and Y planes. The Address reprint request to: Michael S. Kavic, MD, FACS, St. Elizabeth Health Center, third degree of freedom involves rotation around the Surgical Education, 1044 Belmont Ave, PO Box 1790, Youngstown, OH 44501- 1790, USA. Telephone: (330) 480-3124, Fax: (330) 480-3640, E-mail: shaft axis of the instrument. The fourth degree of free- [email protected] dom is a translation (in-and-out) movement of the instru- © 2000 by JSLS, Journal of the Society of Laparoendoscopic Surgeons. Published by ment. Despite advances in instrument design, standard the Society of Laparoendoscopic Surgeons, Inc. JSLS (2000)4:277-279 277 Robotics, Technology, and the Future of Surgery, Kavic MS. laparoscopic instrumentation at the beginning of the 21st Hermes is an another device that can enhance the per- century yet permit only 4 degrees of freedom. formance of a laparoscopic surgeon. Hermes is a voice- activated system that recognizes spoken commands to, Consequently, little question exists that the future among other things, adjust lighting in the operating demands a new approach to these problems. It should room, adjust the operating table, contact another doctor, be noted that just as medicine transitioned from an agrar- or gather information on the Internet. A wealth of infor- ian age to the Industrial age a century ago, a transition mation and databases can be made available to the sur- from the Industrial Age to the Information Age is occur- geon during the procedure, in real-time, to improve ring today. It is reasonable, therefore, to suppose that a patient care. new approach to solving the current problems of mini- mally invasive surgery lies with the application of infor- Scaling, which is a specific control feature of advanced mation technologies. Information technologies can be manipulator systems, can allow the ratio between the categorized as devices that acquire information, devices input and output movement of the system to be changed. that process and transmit information, and those tech- The capability to scale movement and force either nologies and devices that cause a therapeutic interven- upward or downward is available to the surgeon and tion. results in a more exquisite control of the surgical proce- dure. This technology compliments and enhances A great deal of what a physician does on a daily basis human performance as demonstrated by Zeus, one involves information management. For example, a example of an advanced manipulator system. laparoscopic surgeon looks at a video representation of human organs during a surgical procedure on those Zeus is a remote-controlled robot that can perform sur- organs rather than at the actual organs themselves. Vital gical intervention. This device incorporates 3 remote- signs, laboratory data, and radiographs can be represent- controlled interactive arms: one voice-activated arm to ed in a digital format. Doppler ultrasound can give a control the laparoscope and 2 robotic arms to manipu- “false color” image of blood flow. Charting can be per- late purpose-designed instruments. The instruments at formed on a computer. All of this interaction involves the end of the robotic arms are controlled with a joystick information technologies and the substitution of informa- at the surgeon’s workstation. Built-in tremor control (a tion for real-world objects. In effect, “blood and guts” are signal-filtering technique that operates through the com- converted to “bits and bytes.” puter interface) dampens the natural tremor present in a human hand and allows for greater control of the surgi- Information technology and information equivalents, cal instruments. therefore, may be used to resolve some of the hindrances inherent with minimally invasive surgery. For example, Similarly, the da Vinci Surgical System combines robotics robots (the term was first used in Capek’s 1920 play, and computer imaging to enable microsurgery in a Rossum’s Universal Robots, and is derived from the laparoscopic environment. The system consists of a sur- Czechoslovakian word Robata, meaning “forced labor”) geon’s viewing and control console (workstation) inte- can be used to replace human surgical assistants. grated with a high-performance, 3-dimensional monitor system, a patient side-cart consisting of 3 robotic arms Several devices are available to secure and manipulate a that position and maneuver endoscopic instruments, an laparoscope replacing the camera operator. AESOP endoscope, and a variety of articulating instruments. The (Automated Endoscopic System for Optimal Positioning) surgeon’s hand, wrist, and finger movements are trans- is such a device and can be made available to recognize lated into corresponding micro-movements within the voice commands. The system facilitates a laparoscopic patient’s body. Haptics are employed to reproduce the procedure by abolishing the need for an assistant, pro- surgeon’s hand movements in real-time and allow pre- vides stability of view, is associated with less inadvertent cise movements in small spaces. The ability to perform smearing of the lens, and results in less fatigue of the precise movements enable endoscopic coronary-artery- operative team. Visualization of the operative field is bypass procedures on a beating heart and could enable under direct control of the surgeon. Savings occur in improved microsurgery for nerve-related operations such time, and, after the initial expense of the purchase, sav- as prostatectomy. Preservation of the sex nerves to the ings are associated with the reduction in human person- prostate and preservation of the muscles that control uri- nel required to perform the procedure. 278 JSLS (2000)4:277-279 nation offer the possibility of a significant advance in the cise surgery is possible. Surgical workstations remove performance of radical prostatectomy. The da Vinci sys- the surgeon from the immediate operative field and tem has obtained FDA clearance. reduce operator fatigue by improving ergonomics. The operating team can be more completely protected from With these advanced manipulator systems, the surgeon contagious or communicable diseases. sits remote from the patient at an operating console adjusted to provide an optimal ergonomic environment. These information technologies are currently available or Surgery can be performed from the room next to the “just over the horizon.” To progress to the next level of patient or from a location many miles away. Being able minimally invasive surgery, it is necessary to recognize to operate at a workstation remote from the patient obvi- the merits of information technologies, embrace them, ously has benefits in providing advanced surgical care to and develop practical applications for their use. The patients in underserved areas and when operating on choice for their advocacy and for their use lies with us. patients with highly communicable diseases. In the lat- ter instance, the risk of disease transmission is decreased References: when an operating team can be more completely pro- 1. Schurr MO, Buess G, Neisius B, Voges U. Robotics and tected from exposure to contagious tissue and body flu- telemanipulation technologies for endoscopic surgery. Surg ids. Endosc. 2000;14:375-381. The future of surgery is bright and is pregnant with 2. Satava RM, Jones SB. Laparoscopic surgery. Transition to promise. Robots and the use of information technologies the future. Urol Clin North Am. 1998;25:93-102. can result in cost savings by decreasing the number of skilled assistants required to perform laparoscopic sur- 3. Sackier JM, Wang Y. Robotically assisted laparoscopic sur- gery. Newly developed, articulated robotic arms have an gery. Surg Endosc. 1994;8:63-66. increased number of degrees of freedom that mimic many of the functions of the human hand and, in some 4. Schneider I. Robotic tool enhances laparoscopic proce- instances, improve on those functions. Ever more pre- dures. Medical Laser Report. 2000;14:5-6. JSLS (2000)4:277-279 279 http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png JSLS : Journal of the Society of Laparoendoscopic Surgeons Pubmed Central

Robotics, Technology, and the Future of Surgery

Kavic, Michael S.
JSLS : Journal of the Society of Laparoendoscopic Surgeons , Volume 4 (4) – Aug 1, 167
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© 2000 by JSLS, Journal of the Society of Laparoendoscopic Surgeons.
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1086-8089
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1938-3797
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Abstract

EDITORIAL Michael S. Kavic, MD Editor-in-Chief Technology and the creative use of the newly developed These characteristics are hindrances to the diffusion of solid state, charge coupled device (CCD) cameras, minimally invasive surgery, but they are not insurmount- laparoscopes, clip appliers, and energy sources enabled able problems. Rather, they are challenges. Disposable the laparoscopic revolution of the 1990s. And, without instruments can be made in a reusable format with sig- doubt, evolving technology will sustain the development nificant cost savings. Personnel can be cross-trained and of minimally invasive surgery. But the technology that used more efficiently. Three-dimensional laparoscopic fueled the laparoscopic revolution is aged and now hin- cameras are available and can be further refined. These ders further advances in the field. remedies, however, are only “quick fixes.” A more com- plete solution is needed for a comprehensive transition In particular, several characteristics inherent to laparo- to minimally invasive surgery and, ultimately, for the scopic surgery have slowed its more general diffusion evolution to noninvasive, image-guided therapies. into the surgical mainstream. These characteristics include: Operating rooms (OR) designed for open surgery of the mid-20th century have not been easily adapted to a 1) The requirement of laparoscopic surgery for highly laparoscopic environment. Frequently floors of rooms trained personnel to maintain instruments and to used for laparoscopic surgery are cluttered with cables assist during an operative procedure; and wires connecting video monitors, light generators, and energy sources. Tubes linking suction devices to 2) Expensive instrumentation (particularly disposables); suction-aspirators and oxygen lines add to the confusion. 3) Poor ergonomic design of laparoscopic instruments; Towers containing insufflation devices, video recorders, fiberoptic light sources, and monitors are cumbersome 4) Two-dimensional video representation of the and difficult to move. More wires and tubes connect the real-world, 3-dimensional operative field; patient to anesthetic delivery machines and monitoring 5) Work environment not conducive to operator devices. The technologies have been “added on” rather comfort: than “integrated into” the operating theater, and the “added on” look is very evident in a typical operating a. poor monitor placement room. b. inefficient operating instruments sited remote The human arm and hand, although a marvelous device from the operative site for the performance of specific tasks, is another unit that has not adapted well to laparoscopic surgery. The arm- c. limited ability to steer rigid laparoscopic hand unit has 7 degrees of freedom (DOF) that allows instruments the hand to be precisely manipulated in 3-dimensional 6) Lack of haptic (touch) sense; space. However, during minimally invasive surgery, can- nula diameter forbids ingress of a hand into the opera- 7) Surgeon dependence upon a camera operator for tive field and laparoscopic instruments must be substi- visualization of the operative field. tuted for it. First generation laparoscopic instruments have been a poor substitute for the hand and are limited Department of Surgery, Northeastern Ohio Universities College of Medicine, in range to 4 degrees of freedom. The first 2 degrees of Rootstown, Ohio. Department of Surgery, University of Pittsburgh School of freedom concern rotation of the laparoscopic instrument Medicine, Pittsburgh, Pennsylvania. around the point of insertion in the X and Y planes. The Address reprint request to: Michael S. Kavic, MD, FACS, St. Elizabeth Health Center, third degree of freedom involves rotation around the Surgical Education, 1044 Belmont Ave, PO Box 1790, Youngstown, OH 44501- 1790, USA. Telephone: (330) 480-3124, Fax: (330) 480-3640, E-mail: shaft axis of the instrument. The fourth degree of free- [email protected] dom is a translation (in-and-out) movement of the instru- © 2000 by JSLS, Journal of the Society of Laparoendoscopic Surgeons. Published by ment. Despite advances in instrument design, standard the Society of Laparoendoscopic Surgeons, Inc. JSLS (2000)4:277-279 277 Robotics, Technology, and the Future of Surgery, Kavic MS. laparoscopic instrumentation at the beginning of the 21st Hermes is an another device that can enhance the per- century yet permit only 4 degrees of freedom. formance of a laparoscopic surgeon. Hermes is a voice- activated system that recognizes spoken commands to, Consequently, little question exists that the future among other things, adjust lighting in the operating demands a new approach to these problems. It should room, adjust the operating table, contact another doctor, be noted that just as medicine transitioned from an agrar- or gather information on the Internet. A wealth of infor- ian age to the Industrial age a century ago, a transition mation and databases can be made available to the sur- from the Industrial Age to the Information Age is occur- geon during the procedure, in real-time, to improve ring today. It is reasonable, therefore, to suppose that a patient care. new approach to solving the current problems of mini- mally invasive surgery lies with the application of infor- Scaling, which is a specific control feature of advanced mation technologies. Information technologies can be manipulator systems, can allow the ratio between the categorized as devices that acquire information, devices input and output movement of the system to be changed. that process and transmit information, and those tech- The capability to scale movement and force either nologies and devices that cause a therapeutic interven- upward or downward is available to the surgeon and tion. results in a more exquisite control of the surgical proce- dure. This technology compliments and enhances A great deal of what a physician does on a daily basis human performance as demonstrated by Zeus, one involves information management. For example, a example of an advanced manipulator system. laparoscopic surgeon looks at a video representation of human organs during a surgical procedure on those Zeus is a remote-controlled robot that can perform sur- organs rather than at the actual organs themselves. Vital gical intervention. This device incorporates 3 remote- signs, laboratory data, and radiographs can be represent- controlled interactive arms: one voice-activated arm to ed in a digital format. Doppler ultrasound can give a control the laparoscope and 2 robotic arms to manipu- “false color” image of blood flow. Charting can be per- late purpose-designed instruments. The instruments at formed on a computer. All of this interaction involves the end of the robotic arms are controlled with a joystick information technologies and the substitution of informa- at the surgeon’s workstation. Built-in tremor control (a tion for real-world objects. In effect, “blood and guts” are signal-filtering technique that operates through the com- converted to “bits and bytes.” puter interface) dampens the natural tremor present in a human hand and allows for greater control of the surgi- Information technology and information equivalents, cal instruments. therefore, may be used to resolve some of the hindrances inherent with minimally invasive surgery. For example, Similarly, the da Vinci Surgical System combines robotics robots (the term was first used in Capek’s 1920 play, and computer imaging to enable microsurgery in a Rossum’s Universal Robots, and is derived from the laparoscopic environment. The system consists of a sur- Czechoslovakian word Robata, meaning “forced labor”) geon’s viewing and control console (workstation) inte- can be used to replace human surgical assistants. grated with a high-performance, 3-dimensional monitor system, a patient side-cart consisting of 3 robotic arms Several devices are available to secure and manipulate a that position and maneuver endoscopic instruments, an laparoscope replacing the camera operator. AESOP endoscope, and a variety of articulating instruments. The (Automated Endoscopic System for Optimal Positioning) surgeon’s hand, wrist, and finger movements are trans- is such a device and can be made available to recognize lated into corresponding micro-movements within the voice commands. The system facilitates a laparoscopic patient’s body. Haptics are employed to reproduce the procedure by abolishing the need for an assistant, pro- surgeon’s hand movements in real-time and allow pre- vides stability of view, is associated with less inadvertent cise movements in small spaces. The ability to perform smearing of the lens, and results in less fatigue of the precise movements enable endoscopic coronary-artery- operative team. Visualization of the operative field is bypass procedures on a beating heart and could enable under direct control of the surgeon. Savings occur in improved microsurgery for nerve-related operations such time, and, after the initial expense of the purchase, sav- as prostatectomy. Preservation of the sex nerves to the ings are associated with the reduction in human person- prostate and preservation of the muscles that control uri- nel required to perform the procedure. 278 JSLS (2000)4:277-279 nation offer the possibility of a significant advance in the cise surgery is possible. Surgical workstations remove performance of radical prostatectomy. The da Vinci sys- the surgeon from the immediate operative field and tem has obtained FDA clearance. reduce operator fatigue by improving ergonomics. The operating team can be more completely protected from With these advanced manipulator systems, the surgeon contagious or communicable diseases. sits remote from the patient at an operating console adjusted to provide an optimal ergonomic environment. These information technologies are currently available or Surgery can be performed from the room next to the “just over the horizon.” To progress to the next level of patient or from a location many miles away. Being able minimally invasive surgery, it is necessary to recognize to operate at a workstation remote from the patient obvi- the merits of information technologies, embrace them, ously has benefits in providing advanced surgical care to and develop practical applications for their use. The patients in underserved areas and when operating on choice for their advocacy and for their use lies with us. patients with highly communicable diseases. In the lat- ter instance, the risk of disease transmission is decreased References: when an operating team can be more completely pro- 1. Schurr MO, Buess G, Neisius B, Voges U. Robotics and tected from exposure to contagious tissue and body flu- telemanipulation technologies for endoscopic surgery. Surg ids. Endosc. 2000;14:375-381. The future of surgery is bright and is pregnant with 2. Satava RM, Jones SB. Laparoscopic surgery. Transition to promise. Robots and the use of information technologies the future. Urol Clin North Am. 1998;25:93-102. can result in cost savings by decreasing the number of skilled assistants required to perform laparoscopic sur- 3. Sackier JM, Wang Y. Robotically assisted laparoscopic sur- gery. Newly developed, articulated robotic arms have an gery. Surg Endosc. 1994;8:63-66. increased number of degrees of freedom that mimic many of the functions of the human hand and, in some 4. Schneider I. Robotic tool enhances laparoscopic proce- instances, improve on those functions. Ever more pre- dures. Medical Laser Report. 2000;14:5-6. JSLS (2000)4:277-279 279

Journal

JSLS : Journal of the Society of Laparoendoscopic Surgeons – Pubmed Central

Published: Aug 1, 167

References

  • SchurrMOBuessGNeisiusBVogesU Robotics and telemanipulation technologies for endoscopic surgery. Surg Endosc. 2000;14:375–38110790559
  • SatavaRMJonesSB Laparoscopic surgery. Transition to the future. Urol Clin North Am. 1998;25:93–1029529540
  • SackierJMWangY Robotically assisted laparoscopic surgery. Surg Endosc. 1994;8:63–668153867
  • SchneiderI Robotic tool enhances laparoscopic procedures. Medical Laser Report. 2000;14:5–6