TELEROBOTIC SURGERY :THE NEED OF FUTURE

TOPICS TO BE COVERED1.What is Telerobotics?2.What is Telerobotic Surgery?3.History of Telerobotic surgery4. Current trends in Telerobotic surgery5.The DaVinci robotic arm in action6.Control and safety in Telerobotic surgery7. The Indian Scenario

What is Telerobotics?

• The application of telerobotics in the biomedical field has grown rapidly and is showing very promising results. Robot assisted surgery is one of the latest innovations of telerobotics in the field of surgery

What is Telerobotic surgery?

• Though, initially the concept looked like science fiction, the robotic surgical tool was first developed for space use which later graduated as a precision instrument for surgery.THE MYTH -The term robotic surgery also probably gives an impression of a Robot independently operating on a patient in operation theatre. This image is not correct as they do not replace the surgeon at all in the operation theatre. They only maneuver the surgical instruments necessary for surgery and are always under the direct, total control of the surgeon.

• In telerobotic surgery, the robotic tools are not automated robots but teleoperated systems under direct control of the surgeon .

• Laparoscopic surgeries, also called minimally invasive surgeries, are performed via several tiny holes rather than one long incision, reducing post-operative pain and recovery times. The method is increasingly popular.

History of Telerobotics In the early 1990's, NASA's jet propulsion laboratory (JPL) began a

project in telerobotics as part of its emergency response robotic program. The primary aim was to develop a robotic system (HAZBOT) to allow safe exploration of potentially dangerous sites (defusion of bombs, nuclear warfare, battle sites) and handling of hazardous materials (wastes from nuclear reactors).[1] The engineers from NASA and the JPL also intended this for tele surgery in space to enable surgeons on earth to operate on astronauts at the space station. The time lag, however, prevented this from becoming feasible. The procedure was subsequently accelerated by various concomitant developments in computer technology and surgical related advancements. However, for a long time, placing dexterity enhancing robotic systems in the operating room remained an elusive goal.

In the mid 90's there was a sudden surge in the development of robotic surgical technology. Dr. Alan Richards became the first surgeon to operate using the robotic system by performing a laparoscopic cholecystectomy that involved 25 minutes on the console. While the early writing on the new technology covered a variety of surgical procedures, special attention was given to

cardiovascular procedures In the mid nineties, Steve Charles originated the concept of a telerobotic system as a tool to assist the microsurgical procedures.

Subsequently, in 1994-95 JPL engineers developed RAMS based

on surgical requirements provided by Steve Charles using previously developed NASA telerobotics technology. It was a six-degrees-of-freedom surgical robot slave made up of a torso-shoulder-elbow body with a three-axis wrist. The robot manipulator was about 10 inches long and 1 inch in diameter.

Current trends in Telerobotic surgery

• The two pioneering companies making surgical robots were the Computer Motion, founded in 1989 and Intuitive Surgical, formed in 1995.

• Computer Motion developed Zeus robotic surgical system for minimally invasive surgery procedures and the Intuitive Surgical developed the daVinci surgical system consisting of a surgeon's console, a patient-side cart, a high-performance vision system and proprietary instruments and later added endowrist technology to the same.

• The Computer Motion and Intuitive Surgical companies finally merged into a single company, Intuitive Surgical in 2003.

• Technical details

The typical surgical robot architecture follows a classical mater/slave tele-operation set up. This set up consists of two modules: the surgeon console (master) and the robot (slave). The surgeon's console is both viewing and active computer controlled console having set of handles, ergonomically designed along with integrated 3-D vision system and in some cases voice command components. High resolution optical encoder is selected for transmitting the command from master arm to slave arm.

The robotic system interacting with the patient includes usually three robotic arms; two to manipulate the surgical instruments and a third to position the endoscopic camera at the optimal position. The surgeon controls the position of the robotic arms and in turn surgical instruments via handles at the console and third endoscopic camera arm by voice command, providing the surgeon precise and stable view of the actual surgical field.

Coronary Artery Bypass Graft (CABG) surgery

  Surgeons for Minimally Invasive Surgery are studying the use

of the latest technology —  a $1.4 million robot named da Vinci that, with a human at the controls, filters out tremor, enhances precision and offers three-dimensional imaging.

Surgeon

• Surgeon's console (Master)

• Robotic arms (Slave)-2 arms

• Microsurgical instruments

Endoscopic camera

• Visualization of operating field

Robotic arm (voice activated)-3rd arm

• Endoscopic camera

Assistant/nurse

• For setting robotic arms

• For changing instruments

Architecture of the First Telerobotic surgery• Personal computers of the 486 series with a VGA graphic card were used. The cameras were Sony solid-state cameras, with

software actuated moms and microcameras.• The robot is an I.B.M. Scara 7565 robot with 4 degrees of liberty which utilises AML2 language.• The mechanical system on the robot is equipped with a biopsy probe with a dynamic sensor which measures the forces exerted on the body of the patient with an accuracy of 0.1 gram.• The data produced are transmitted to the data management computer installed at the centre of the surgical station. These data are also transmitted to the remote surgeon.• The robot has an ecographic probe at the extremity of its arm, to monitor the interior of the body being examined, the data are transmitted to both the surgical station and the remote surgeon. In addition, the extremity is constructed to enable it to carry scalpels, probes and instruments for laparoscopy. Instruments can be changed manually or automatically.

Surgical roboticized stationPatientRobotCamera SensorsData processing computerOverall control and transmission computer1talyAJ.S.A. satellitdsUnderwater optical fibre networkInternational computer networkSurgeonOverall control and transmission computerPeripheral control unit54

5.The DaVinci robotic arm in action

• FIGURE 1: The Da Vinci Telerobotic Surgical System permits the surgeon to perform an operationon a patient from a remote site. Currently, the FDA requires the surgeon to sit physically in thesame room as the patient on whom he is operating.

FIGURE 2: The Da Vinci Telerobotic Surgical System consists of three parts:

A. the surgeon’s console; B. the video electronics tower; and

C. the robotic’s tower supporting three robotic arms.

FIGURE 3:The surgeon sits at the computer console.He viewsa virtual operative field through a binocular 3-dimensionalimaging system. He sits in a comfortable ergonomically correct position with arms supported by a rest. His feet activate several peddles

that control various aspects of the robot’s movements.

• FIGURE 4:The surgeon’s console contains the binocular 3-dimensional imaging system.The surgeon immerses himself within a virtual operative field that is viewed through the binocular viewing finders.His arms are supported by the arm rest. Foot peddles control various adjustments of the robotic arms and instruments.

• FIGURE 5: The surgeon inserts his hands into a “master” that translates motions of his hands into motions of the robotic arms and hand-like instruments. The surgeon acts as the “master” and the robot as the “slave” in this telerobotic “master-slave” system.Da Vinci only duplicates the motions of the surgeon. Da Vinci does not initiate any actions on its own volition

• FIGURE 6: The robotics tower supports the three robotic arms. This photograph shows the Da Vinci robotics tower on the right and an AESOP 3000 (Computer Motion Inc, Santa Barbara, CA), a voice controlled robotic camera holder, on the left.

• FIGURE 7: The Da Vinci robotics tower rolls next to the patient who is on the operating room table.

• FIGURE 8: The Da Vinci robotic arms hold two surgical instruments and a video telescope. The hand-like surgical instruments move with 7 degrees of freedom and two degrees of axial rotation. The 12 mm video telescope contains two separate 5 mm telescopes that are attached to two separate 3 chip video cameras. The offset of the two telescopes permit a telecast of a true 3-dimesional image through the binocular imaging system The surgeon sees a 3-dimensional virtual operative field.

• FIGURE 9: The three robotic instruments are inserted into the patient’s abdomen or chest through three laparoscopic trocars. The abdomenor chest are distended with carbon dioxide to give the surgeon space in which to work. The trocars have valves that prevent the gas from escaping.

• FIGURE 10: The robotic arms are attached to the trocars. The robotic arms are then inserted into the patient’s abdomen or chest.

• FIGURE 11: This photograph shows the connection between the robotic arm and the laparoscopic trocar. The robotic instrument enters the patient through the metal trocar.

• FIGURE 12: This photograph shows two robotic instruments within a patient’s abdomen. The instrument on the right is an electrocautery hook that cuts tissue. The instrument on the left is a Cadiere grasper that is used retract the intestines or other structure. The hole in the background is a hernia through an old incision.

6.Control and safety in Telerobotic surgery

• LIMITATIONS- The initial capital cost ranging from one million to several million dollars is

prohibitive for its free use. However, multi-specialty utilization of robotic technology along with improvement in surgical outcome and more expeditious return to work will make this approach cost-effective, justifying investment in this technology. The time taken for the surgery is often more as compared to the conventional surgery. However, operating time is likely to reduce significantly with more familiarity and decreasing learning curve.

Another current limitation is that the presently available instruments are not yet small and fine enough to perform delicate micro-vascular surgeries like free flaps, microneurorrhaphy and digital replantations.

Another limitation noted is that there is no haptic feedback which often make

the surgeon feel detached from the patient and the procedure. However, high magnification of operative site negates this draw back .Also a learning curve is always there but after dedicated training and some experience, one feels comfortable working with the instrumentation and doing the surgery without actually touching the patient. Clearly, a lot of work needs to be done and the dividends are expected to be equally pleasing.

• ADVANTAGES – The use of telerobotics technology during

surgery can greatly improve the surgical outcome by providing surgeons with 1.greater precision

2. elimination of hand tremors 3. increased range of motion and

enhanced 3-D visualization.

• However, the robots are never likely to replace the highly evolutionized human hand and rather than replacing the human hand, this technology will help to retain the benefits of the human hand along with its superlative optimization to achieve the goal of optimal precision and predictability. With the continued evolution of robotic surgical technology, the robots are expected to become smaller, faster, lighter and smarter with exponential increased application in microsurgery.

• The future of RAMS seems to be promising and continuing advancement of this technology holds the key. 

7. The Indian Scenario

Robotics In Surgery Is It Worth The Investment?

Robots in Surgery

• Definition

• Surgical assisting devices

• Surgeon-computer-instrument interface

• Minimally invasive surgery

Da Vinci surgical system

• NASA Ames research centre - space surgery

• DARPA – battlefield surgery

• 1994 – first robotic operation – intestinal anastomosis

Da Vinci surgical system

• 1994 - Intuitive Surgical

• 1997 – First robotic procedure: cholecystectomy

• 2000 – 200 patient trial

• 2005 - 350 units sold

• 2006 – 70,000 operations done

A matter of cost• €1,000,000 initial

cost

• €110,000 maintenance cost per annum

• Can the benefits of robotic surgery pay for its costs?

Methods

• Cost benefit analysis

• Da Vinci

• For individual surgical procedures

• Cholecystectomies, adrenalectomies, gastric bypass surgery, cardiac bypass grafting, prostatectomies etc.

Methods

• Comparison against traditional open surgery and standard minimally invasive surgery

• Hospital stay, operation time, cost of equipment

• Pubmed and Google Scholar

• Nissen fundoplication and Radical retropubic prostatectomy

Results: Initial Costs• Initial

purchase cost - €1,031,810

• €737 per procedure

Item Cost (Euro)

da Vinci™ system including Surgeon console Surgical cart housing robotic arms 3-D digital camera Installation and testing

956,550

Endoscopes 0° endoscope 30° endoscope

16,50016,500

Sony 20’ monitor 3,800

Starter set of multispecialty training instruments

11,815

Starter set of accessories and disposables

16,645

Delivery cost 10,000

TOTAL 1,031,810

Results: Maintenance costs

• Maintenance costs

• €110,000 per year

• €550 per procedure

Theatre, hospital, and convalescence costs

• Theatre cost, €100.90 per hour

• Hospital stay cost, €432 per day

• Time away from work, €83 per day

Item Cost per hour (Euro)

Surgeons’ fees* Primary surgeon (1st year

specialist registrar) First assistant (1st year senior

house officer)

27.7017.70

Anaesthetist’ fees* (1st year specialist registrar)

27.70

Nurses’ fees Scrub nurse Circulating nurse

13.9013.90

TOTAL 100.90

Nissen FundoplicationItem (average values) Open method Standard minimally-

invasive surgeryRobotic surgery

Operative time 0.8 hours (50 minutes) 1.0 hours (60 minutes) 1.8 hours (107 minutes)

Hospital stay time 6.1 days 2.2 days 2.2 days

Convalescence time 35 days 12 days 12 days

Disposable equipment costs Not Applicable* €1006 €1558

1 Costi, R., Himpens, J., Bruyns, J., Cadiere, G. B.: Robotic Fundoplication: From Theoretic Advantages to Real Problems. J Am Coll Surg. Vol. 197 No.3 Pg. 500-507 Sept 2003

2 Richards, K. F., Fisher K. S., Flores J. H., Christensen B. J.: Laparoscopic Nissen fundoplication: cost, morbidity and outcome compared with open surgery. Surg Laparosc Endosc. Vol. 6 No 2 Pg. 140-143 Apr 1996

Nissen Fundoplication

• Versus open surgery

• Shorter hospital stay, shorter time to return to work

• Longer operating time, cost of disposable equipment, cost of maintenance, cost of initial purchase

• Cost savings of €647.90 per procedure

Nissen Fundoplication

• Versus standard minimally invasive surgery

• No cost benefit

• Longer operating time, cost of disposable equipment, cost of maintenance, cost of initial purchase

• Increased cost of €1919.70 per procedure

Radical retropubic prostatectomyItem (average values) Open method Standard minimally-

invasive surgeryRobotic surgery

Operative time 2.7 hours (163 minutes) 4.1 hours (246 minutes) 2.5 hours (148 minutes)

Hospital stay time 3.5 days 1.3 days 1.2 days

Convalescence time 47 days 47 days 30 days

Disposable equipment costs €75 €533 €1705

1 Lotan, Y., Cadeddu, J. A., Gettman, M. T.: The New Economics of Radical Prostatectomy: Cost Comparison of Open, Laparoscopic and Robot Assisted Techniques. J Urol. Vol. 172 Pg. 1431-1435 Oct 2004

2 Menon, M., Shrivastava, A., Tewari, A.: Laparoscopic Radical Prostatectomy: Conventional and Robotic. J Urol. Vol 66 Pg 101-104. 2005

Radical retropubic prostatectomy

• Versus open surgery

• Shorter operating time, shorter hospital stay, shorter time to return to work

• Cost of disposable equipment, cost of maintenance, cost of initial purchase

• Cost savings of €492.20 per procedure

Radical retropubic prostatectomy

• Versus standard minimally invasive surgery

• Shorter operating time, shorter hospital stay, shorter time to return to work

• Cost of disposable equipment, cost of maintenance, cost of initial purchase

• Increased cost of €843.40 per procedure

Discussion

• Cost effective compared to open surgery

• Expensive new technology

• Potential for major improvements

Conclusions• Should the CUH

buy a da Vinci surgical robot?

• Probably not advisable

• Current prices are prohibitive but the technology has tremendous potential