ROBOTIC SURGERY



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ROBOTIC SURGERY

A SEMINAR ON CURRENT TOPICS IN COMPUTING (COM 425)

PRESENTED BY

OMONIWARI EMILIA BOMA

2009HDM/2778/CS

TO THE DEPARTMENT OF COMPUTER SCIENCE

SCHOOL OF SCIENCE AND INDUSTRIAL TECHNOLOGY, ABIA STATE POLYTECHNIC, ABA

IN PARTIAL FULFILMENT FOR THE AWARD OF HIGHER NATIONAL DIPLOMA (HND)

SUPERVISED BY: ENGR. DIMOJI

SEPTEMBER, 2011

ABSTRACT

Robotic surgery make use of robots to perform surgery. Major potential advantages of robotic surgery are precision and miniaturization. With skilled surgeons and the robotic system, we can now use minimally invasive techniques in even the most complicated procedures like cardiac surgery, gastrointestinal surgery, gynecology, urology, pediatrics, orthopedics etc. The software is “command central” for the device’s operation, da Vinci, Aesop, Hermes etc, are different kinds of the robotic systems. The combination of increased view and tireless dexterity is helping us to overcome some of the limitations of other types of less invasive surgery.

1. INTRODUCTION

Robotic surgery is the use of robots in performing surgery. Major potential advantages of robotic surgery are precision and miniaturization. Further advantages are articulation beyond normal manipulation and three-dimensional magnification. At present, surgical robots are not autonomous, but are always under the control of a surgeon. They are used as tools to extend the surgical skills of a trained surgeon.

Robotic surgery is different from minimally invasive surgery. Minimally invasive surgery (sometimes called laparoscopic surgery) is a general term for procedures that reduce traumatic by performing operations through small ports rather than large incisions. Minimally invasive surgery is now common place for certain procedures. But until now, we haven’t been able to use minimally invasive techniques for more complex operations. With our skilled surgeons and the robotic system, we can now use minimally invasive techniques in even the most complicated procedures like cardiac surgery, gastrointestinal surgery, urology, pediatrics, orthopedics etc.

1.1 APPLICATIONS OF ROBOTIC SURGERY

In early 2000 the field of general surgical interventions with the da vinci device was explored by surgeons at Ohio State University. Reports were published in esophageal and pancreatic surgery for the first time in the world and further data was subsequently published by Horgan and his group at the University of Illinois and then later at the same institution by others. In 2007, the University of Illinois at Chicago medical team, led by Prof. Pier Cristoforo, reported a pancreatectomy and also the Midwest fully robotic whipped surgery. The same team of surgeons performed with world’s first fully minimally invasive liver resection for living donor transplantation, removing 60% of the patient’s liver, yet allowing him to leave the hospital just a couple of days after the procedure, in very good condition.

1.1.1 UROLOGY

Urology is used in the removing of the prostrate gland for cancer, repair obstructed kidneys, repair bladder abnormalities and removing diseased kidneys. New minimally invasive robotic devices using steerable flexible needles are currently being developed for use in prostrate brachytherapy.

2. RADIOSURGERY

The Cyberknife Robotic Radiosurgery System uses imaged guidance and computer controlled robotics to treat tumors throughout the body by delivering multiple beams of high-energy radiation to the tumor from virtually any direction.

3. PEDIATRICS

Surgical robotics has been used in many types of pediatric surgical procedures including: tracheoesophageal fistula repair, cholecystectomy, nissen fundoplication, morgagni’s hernia repair, kasai portenterostomy, congenital diaphragmatic hernia repair, and others. The results from this procedures are less pain, faster recoveries, shorter hospital stays, smaller scars, and happier patients and families.

4. ORTHOPEDICS

Robotic surgery is a tool which is used for total hip replacement, total kneel replacement and anterior cruciate ligament reconstructions.

5. GYNECOLOGY

Robotic surgery in gynecology is one of the fastest growing fields of robotic surgery. This includes the use of the da vinci surgical system in benign gynecology and gynecological oncology. Robotic surgery can be used to treat fibroids, abnormal periods, endometriosis, ovarian tumors, pelvic prolapse, and female cancers. Using the robotic system, gynecologists can perform hysterectomies, myomectromies, and lymph node biopsies. The need for large abdominal incisions is virtually eliminated.

6. CARDIOLOGY AND ELECTROPHYSIOLOGY

The stereo taxis Magnetic Navigation System (MNS) has been developed to increase precision and safety in ablation procedures for arrhythmias and atrial fibrillation while reducing radiation exposure for the patient and physician, and the system utilizes two magnets to remotely steerable catheters. The system allows for automated 3-0 mapping of the heart and vasculature, and MNS has also been used in interventional cardiology for guiding stents and leads in PCI and CTO procedures, proven to reduce contrast usage and access tortuous anatomy unreachable by manual navigation. At present, three types of heart surgery are being performed on a routine basis using robotic surgery systems. These three surgery types are:

❖ Atrialspal defect repair: The repair of a hole between the two upper chambers of the heart.

❖ Mitral value repair: The repair of the value that prevents blood from regurgitation back into the upper heart chambers during contraction of the heart.

❖ Coronary artery bypass: Rerouting of blood supply by bypassing blocked arteries that provide blood to the heart.

7. GASTROINTESTINAL SURGERY

Multiple types of procedures have been performed with either the zeus or dan vinci robot systems, including bariatric surgery. Surgeons at various universities initially published cases series demonstrating different techniques and the feasibility of GI surgery using the robotic devices. Specific procedures have been more fully evaluated, specifically esophageal fundoplication for the treatment of gastroesophageal reflux and Heller myotomy for the treatment of achalasis. Other gastrointestinal procedures including colon resection, pancreatectomy, esohagectomy and robotic approaches to pelvic disease have also been reported.

2. HISTORY

In 1985, a robot, the PUMA 560, was used to place a needle for a brain biopsy using CT guidance. In 1988, the PROBOT, developed at Imperical College London, was used to perform prostatic surgery. The ROBODOC from Integrated Surgical Systems was introduced in 1992 to mill out precise fittings in the femur for hip replacement. Further development of robotic systems was carried out by intuitive surgical with the introduction of the da vinci surgical system and computer motion with the AESOP, and the ZEUS robotic surgical system. (Intuitive surgical bought computer motion in 2003; zeus is no longer being actively marketed).

The da vinci surgical system comprises three components: a surgeon’s console, a patient-side robotic cart with four arms manipulated by the surgeon (one to control the camera and three to manipulate instruments), and a high definition 3D vision system. Articulating surgical instruments are mounted on the robotic arms which are introduced into the body through cannulas. The original telesurgery robotic system that the da vinci was based on was developed at SRI international in Menco Park with grant support from DARPA and NASA. Although the telesurgical robot was originally intended to facilitate remotely performed surgery in battlefield and other remote environments, it turned out to be more useful for minimally invasive on-site surgery. The patents for the early, prototype were sold to intuitive surgical in Mountain View, California.

3. DIFFERENT TYPES OF ROBOTIC SYSTEMS

Computer motion of Santa Barbara California has become the leading producer of medical robotics. Different types of robot are da vinci, Aesop, Hermes, and Zeus.

The da vinci surgical system was the first operative surgical robot. Products like Aesop, Hermes and Zeus are the next generation of surgical equipment and are used together to create a highly networked and efficient operating room.

3.1 DA VINCI SURGICAL SYSTEM

Incorporating the latest advancements in robotics and computer technology, the da vinci surgical system was the first operative surgical robot deemed safe and effective by the United State Food and Drug Administration for actually performing surgery.

The da vinci system was developed by intuitive surgically system, which was established in 1995. Its founders used robotic surgery technology that had been developed at SRI international, previously known as Stanford Research Institute. The FDA approved da vinci in May 2001. The da vinci is a surgical robot enabling surgeons to perform complex surgeries in a minimally invasive way, in a manger never before experienced to enhance healing and promote well-being. It is used in over 300 hospitals in the America and Europe. The da vinci was used in at least 16,000 procedures in 2004 and sells for about 1.2 million dollars. Until very recently surgeons options include traditional surgery with a large open incision or laparoscopy, which uses small incisions but is typically limited to very simple procedures. The da vinci surgical system provides surgeons with an alternative to both traditional open surgery and conventional laparoscopy, putting a surgeon’s hands at the controls of a state-of-the-art robotic platform. The da vinci system enables surgeons to perform even the most complex and delicate procedures through very small incisions with unmatched precision. It is important to know that surgery with da vinci does not place a robot at the controls; surgeon is controlling every aspect of the surgery with the assistance of the da vinci robotic platform. Thus da vinci is changing the experience of surgery for the surgeon, the hospital and most importantly for the patient.

There are four main components to da vinci: the surgeon console, patient-side cart, Endo Wrist Instruments, and Insite Vision System with high resolution 3D endoscope and image processing equipment.

3.1.1 SURGEON CONSOLE

The surgeon is situated at the console several feet away from the patient operating table. The surgeon has his head tilted forward and his hands inside the system’s master interface. The surgeon sits viewing a magnified three-dimensional image of the surgical field with a real-time progression of the instruments as he operates. The instrument controls enable the surgeon to move within a one cubic foot area of workspace.

2. PATIENT-SIDE CART

This component of the system contains the robotic arms that directly contact the patient. It consists of two or three instrument arms and one endoscope arm. As of 2003, intuitive launched a fourth arm, costing 175,000 dollars, as a part of a new system installation or as an upgrade to an existing unit. It provides the advantages of being able to manipulate another instrument for complex procedures and removes the need for one operating room nurse.

3. DETACHABLE INSTRUMENTS

The Endowrist detachable instruments allow the robotic arms to maneuver in ways that simulate fine human movements. Each instrument has its own function from suturing to clamping, and is switched from one to the other using quick-release levers on each robotic arm. The device memorizes the position of the robot arm before the instrument is replaced so that the second once can be reset to the exact same position as the first. The instrument’s abilities to rotate in full circles provide an advantage over non-robotic arms. The intuitive master technology also has the ability to filter out hand tremors and scale movements. As a result, the surgeon’s large hand movements can be translated into smaller ones by the robotic device. Carbon dioxide is usually pumped into the body cavity to make more room for the robotic arms to maneuver.

4. THREE-DIMENSIONAL VISION SYSTEM

The camera unit or endoscope arm provides enhanced three-dimensional images. This high resolution real-time magnification showing the inside of the patient allows the surgeon to have a considerable advantage over regular surgery. The system provides over a thousand frames of the instrument position per second and filters each image through a video processor that eliminates background noise. The endoscope is programmed to regulate the temperature of the endoscope tip automatically to prevent fogging during the operation. Unlike the navigator control, it also enables the surgeon to quickly switch views through the use of a simple foot pedal.

1. AESOP

Aesop’s function is quite simple, merely to maneuver a tiny video camera inside the patient according to voice controls provided by the surgeon. By doing so, Aesop has eliminated the need for a member of the surgical team to hold the endoscope in order for a surgeon to view his operative field in a closed chest procedure. This advance marked a major development in closed chest or post-access bypass techniques, as surgeons could now directly and precisely control their operative field of view. Today about 1/3 of all minimally invasive procedures use Aesop to control an endoscope. Considering each Aesop machine can handle 240 cases a year, only 17,000 machines are needed to handle all minimally invasive procedures a relatively small number considering the benefits of this technology.

2. ZEUS

Zeus is the youngest and most technically advanced robotic aid. Zeus contains robotic arms that mimic conventional surgical equipment and a viewing monitor that gives the surgeon a view of his operative field. More importantly, zeus enables a surgeon to operate on a patient using joystick like handles which translate the surgeon’s hand movements into precise micro-movements inside the patient. For example a 1-cm movement by a surgeon’s hand is translated into a 1-cm movement of the surgical tip held by a robot arm. Zeus also has the unique capability of reducing human hand tremor and greatly increasing the dexterity of the surgeon. Zeus allows surgeons to go beyond the limits of MIS enabling a new class of delicate procedures currently impossible to perform. The main disadvantage is high machine cost. It is around one million dollars. Its FDA approval is pending.

3. HERMES

Unlike Aesop and Zeus, Hermes does not use robot arms to make the operating room more efficient. Rather Hermes is platform designed to network the OR, integrating surgical devices, which can be controlled by simple voice commands. Many pieces of surgical equipment are outside the range of scarcity for the surgeon and must be manipulated by a surgical staff while Hermes enables all needed equipment to be directly under the surgeon’s control. Hermes can integrate tables, lights, video cameras and surgical equipment decreasing the time and cost of surgery. Ultimately Hermes decreases the need for a large surgical staff and facilitates the establishment of a networked, highly organized OR. Ultimately computer motion is working to bring Hermes into 84,000 operating rooms worldwide.

4. ADVANTAGES AND LIMITATIONS OF ROBOTIC SURGERY

Major advances aided by surgical robots have been remote surgery, minimally invasive surgery and unmanned surgery. Some major advantages of robotic surgery are precision, miniaturization, smaller incisions, decreased blood loss, less pain, and quicker healing time. Further advantages are articulation beyond normal manipulation and three-dimensional magnification, resulting in improved ergonomics. Robotic techniques are also associated with reduced duration of hospital stays, blood loss, transfusions, and use of pain medication.

With the cost of the robotic at $1,200,000 dollars and disposable supply costs of $1,500 per procedure, the cost of the procedure is higher. Additional surgical training is needed to operate the system. Numerous feasibility studies have been done to determine whether the purchase of such systems are worthwhile. As it stands, opinions differ dramatically. Surgeons reports that, although the manufacturers of such systems provide training on this new technology, the learning phase is intensive and surgeons must operate on twelve to eighteen patients before they adapt. Moreover during the training phase, minimally invasive operation can take up to twice as long as traditional surgery, leading to operating room tie ups and surgical staffs keeping patients under anesthesia for long periods. Patients surveys indicate they chose the procedure based on expectations of decreased morbidity, improved outcomes, reduced blood loss and less pain. Higher expectations may explain higher rates of dissatisfaction and regret.

Advantages of this technique are that the incisions are small and patient recovery is quick in traditional open-heart surgery, the surgeon makes a ten to twelve-inch incision, then gains access to the heart by splitting the sternum (breast bone) and spreading open the rib cage. The patient is then placed on a heart-lung machine and the heart is stopped for a period of time during the operation. This approach can be associated with postoperative infection and pain, and prolonged time to complete recovery. Because patient recovery after robot-assisted heart surgery is quicker, the hospital stay is shorter. On average patients leave the hospital two to five days earlier than patients who have undergone traditional open-heart surgery and return to work and normal activity 50% more quickly. Reduced recovery times are not only better for the patient, they also reduce the number of staff needed during surgery, nursing care requirement after surgery, and, therefore, the overall cost of hospital stays.

Compared with other minimally invasive surgery approaches, robot-assisted surgery gives the surgeon better control over the surgical instruments and a better view of the surgical site. In addition, surgeons no longer have to stand throughout the surgery and do not get tired quickly. Naturally occurring hand tremors are filtered out by the robot’s computer software. Finally, the surgical robot can continuously be used by rotating surgery teams. While the use of robotic surgery has become an item in the advertisement of medical services, critics point out that studies that indicate that long-term results are superior to those after laparoscopic surgery are lacking.

4.1 ADVANTAGES OF ROBOTIC SURGERY

Robotic surgery offers many benefits over traditional surgery. The robotic surgical system is great for patients and for surgeons. Robotic surgery gives us even greater vision, dexterity and precision than possible with standard minimally invasive surgery, so we can now use minimally invasive techniques for a wider range of procedures. The patient side benefits include:

1) Reduced pain and trauma

2) Fewer complications

3) Less blood loss and need for transfusion

4) Less post-operative pain and discomfort

5) Less risk of infection

6) Shorter hospital stay

7) Faster recovery and return to work

8) Less scarring and improved appearance

4.1 LIMITATIONS OF ROBOTIC SURGERY

1) Current equipment is expensive to obtain, maintain, and operate.

2) Surgeons and staff need special training.

3) Data collection of procedures and their outcomes remains limited.

5. SUMMARY

Robotic surgery, computer-assisted surgery, and robotically-assisted surgery are terms for technological developments that use robotic system to aid in surgical procedures. Robotically-assisted surgery was developed to overcome the limitations of minimally invasive surgery. Robotic surgery has become an item in the advertisement of the medical service. Some of its major advantages are precision, miniaturization, smaller incisions, decreased blood loss, less pain, and quicker healing time.

5.1 CONCLUSION

Robotic surgery is an emerging technology in the medical field. It gives us even greater vision, dexterity and precision than possible with standard minimally invasive surgery, so we can now use minimally invasive techniques for a wider range of procedures. But it’s main drawback is high cost beside the cost, robotic system still has many obstacles that it must overcome before it can be fully integrated into the existing healthcare system. More improvements in size, tactile sensation, cost, are expected for the future.

REFERENCES

Ahmed, Khan, Vats, Nagpal, Priest, Patel, Vecht, Ashrafian (2009; 7:431-440); “Current Status of Robotic Assisted Pelvic Surgery and Future Developments”. New York.

Gina Kolata (2010). “Results Unproven, Robotic Surgery Wins Converts”. The New York Times.

Kypson, Alan, Chitwood Jr, Randolph (2004: 1(2): 87-92) “Robotic Applications in Cardiac Surgery”. New York International Journal.

Leslie Versweyveld (1999)” ZEUS Robot System Reverses Sterilization to Enable of Birth of Baby Boy’. Virtual Medical Worlds Monthly.

Melvin, Dundon, Talamini, Horgan, (2005; 138 (4): 553-8) “Computer Enhanced Robotic Telesurgery Reduces Esophageal Perforation During Heller Myotomy Surgery”. Colombia.

Talamini, Chapman, Horgan, Melvin, (2003; 17: 1521-1524) “Evaluation of 211 Robotic Surgical Procedures. Mexico.





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