ROBOTIC SURGERY
Fantasy is today’s reality
Changing the culture of surgery!

One of the latest technical advances in minimally-invasive surgery is robotic surgery. Minimally-invasive, laparoscopic surgery has achieved excellent outcomes for patients in reducing the length of hosptial stays, the need for pain medication, the time needed to recover from surgery, providing a better cosmetic result. As the next step in technology, robotic surgery offers all the benefits of laparoscopic surgery along with the potential for increased precision and effectiveness.

DEFINITION
The word “Robot” is taken from the Czech robota, meaning forced labor, has evolved in meaning from dumb machines that perform menial, repetitive tasks to the highly intelligent anthropomorphic robots of popular culture.

Robots have often been thought of as machines that replace humans. These machines have been used in manufacturing, space exploration, and other areas. However, they can also be used as surgical tools. Many people think of these tools as devices used to replace the physician. However, they are used to complement human surgeons.

The field of robotics provides an enhancement of human performance, the ability to project surgical expertise to remote and distant places, and recreation of a patient in a "virtual" form. Robotics takes the surgeon’s motions and changes them into electronic signals which through a computer can be enhanced. The result is performing a procedure with greater accuracy and precision..

HISTORY
The history of robotics in surgery begins with the Puma 560, a robot used in 1985 by Kwoh et al to perform neurosurgical biopsies with greater precision.[6,11]] Three years later, Davies et al performed a transurethral resection of the prostate using the Puma 560.[12] This system eventually led to the development of PROBOT, a robot designed specifically for transurethral resection of the prostate. ROBODOC, a robotic system was designed to machine the femur with greater precision in hip replacement surgeries.[1] ROBODOC was the first surgical robot approved by the FDA.

The first coronary bypass surgery in a human patient using robotic arms manipulated by the surgeon was performed by Dr. Ralph Damiano at the Milton S. Hershey Medical Center, Pennsylvania.

WHAT IS ROBOTIC SURGICAL SYSTEM ?
The robotic surgical system is a computer-enhanced minimally invasive surgical system consisting of three components:

High-definition camera providing the surgeon a true, minimally invasive view of the surgical field, magnified up to 15 times. With this technology, the surgeon can more easily identify vital anatomy such as the delicate nerves and blood vessels surrounding specific anatomy.

Surgical cart including the instruments and three robotic arms whereby the laparoscope and two instruments are inserted. The instruments are designed to mimic the movement of the surgeon's hands, wrists and fingers. Their extensive range of motion allows precision that is not available in standard minimally invasive procedures.

Surgeon console containing the master controls that the surgeon uses to manipulate the instruments. The handles or "Masters" translate the surgeon's natural hand and wrist movements into corresponding, precise and scaled movements. The instruments are only able to move when commanded by the surgeon.

Robot can accomplish what the human surgeon cannot because of its ability to mimic the human hand within a small, contained space. The EndoWristTM Instruments transform the surgeons’ wrists, hand and fingers into tiny instruments. During the procedure, while the console surgeon operates the sophisticated robot from a distance, the bedside surgeon is responsible for placement of the correct surgical ports and directing the robot into the patient.

The da Vinci surgical robot is the first robotic system licensed for use in American operating rooms. It was granted FDA approval in 2000.
The FDA cleared ZEUS robotic surgical system in October 2001 to assist in the control of blunt dissectors, retractors, graspers, and stabilizers during laparo-scopic and thoracoscopic surgeries.

BENEFITS OF ROBOTIC SURGERY
Benefits to Patient
- Reduced pain and trauma to the body
- Less blood loss and need for transfusions
- Less post-operative pain and discomfort
- Less risk of infection
- Shorter hospital stay
- Faster recovery and return to work.
- Allows for a minimally-invasive approach in surgery which means much less scarring and improved comesis

Benefits to surgeon
greater precision and dexterity where fine suturing techniques are required robotic arms eliminate the tremor of a surgeon's hands improved technique for surgery reduced fatigue during surgery - comfortable seated position at robotic controls.

HOW IS ROBOTIC SURGERY DIFFERENT FROM MINIMALLY INVASIVE SURGERY?
Minimally invasive surgery is a general term for procedures that reduce trauma by performing operations through small ports rather than large incisions. Minimally invasive surgery is now a common place for certain procedures. But until now, we haven’t been able to use minimally invasive techniques for more complex operations. With skilled surgeons and the da Vinci™ Surgical System, we can now use minimally invasive techniques in even the most complicated procedures. What all a robot can do for surgeons ?

Robotic surgery can, in fact, be used for a number of procedures within multiple specialties including: general surgery (i.e. laparoscopic adrenalectomy, gastric bypass) gynecological surgery (i.e. cystocele repair, hysterectomy, tubal ligation) thoracic surgery (esophagectomy, lung biopsy, tumor resection) urological surgery (donor nephrectomy, prostatectomy, and ureter harvest) vascular surgery (aortic abdominal aneurysm and vena cava tumor) The Challenge and its solution According to the surgeons, the biggest challenge faced was minimising the "lag" effect — if the time delay between the surgeons and the robot was too long, or slightly out of sync, it would destroy the timing and "feel" of the surgeons. Experts believe that a time delay of 330 milliseconds would be the maximum acceptable delay, but thanks to years of research and development by France Telecom, this was cut down to a mere 150 milliseconds for the operation. The Learning Curve

The FDA requires manufacturers to train surgeons before they can use robotic surgical systems on patients. Ogden says there is a significant learning curve involved. "As it stands now, it takes 12-18 patients before surgeons feel comfortable and before surgeons are able to perform the procedures as quickly as with standard techniques," he says.
Paul Nolan of Computer Motion says typical training for surgeons who buy the ZEUS system involves up to 40 hours, including experience at animal and cadaveric labs.

The Future of Robotic Surgery
Robotic surgery is in its infancy. Many obstacles and disadvantages will be resolved in time and no doubt many other questions will arise. Many questions have yet to be asked; questions such as malpractice liability, credentialing, training requirements, and interstate licensing for tele-surgeons, to name just a few.

Many future "advancements" are already being researched. Some laboratories, including the authors' laboratory, are currently working on systems to relay touch sensation from robotic instruments back to the surgeon. Other laboratories are working on improving current methods and developing new devices for suture-less anastomoses. When most people think about robotics, they think about automation. The possibility of automating some tasks is both exciting and controversial. Future systems might include the ability for a surgeon to program the surgery and merely supervise as the robot performs most of the tasks. The possibilities for improvement and advancement are only limited by imagination and cost.

By providing the use of a variety of technologies to enhance the capabilities of human surgeons, robotics will become an increasingly vital component in the medical world. Doctors of the next century must learn to use this information to complement their capabilities in order to provide better patient care.

REFERENCES
• Mack, M.J, Minimally Invasive and Robotic Surgery JAMA, 2001; 285: 5.
• Schulam, P.G., et al, Telesurgical Mentoring, Surgical Endoscopy, 1997; 11: 1001-1005.
• Sackier, J.M., Wang, Y., Robotically Assisted Laparoscopic Surgery, from Concept to
• Development, Surgical Endoscopy, 1994; 8.
• Falcone, T., Goldberg, J., Garcia-Ruiz, A., Margossian, H., Stevens, L., Full Robotic
• Assistance for Laparoscopic Tubal Anastomosis; First Case Report, Journal of
• Laparoendoscopic and Advanced Surgical Techniques, 1999; 9(1): 107-113.
• Butner, S.E., Ghodoussi, M., Wang, Y Robotic Surgery - The Transatlantic Case
• submitted for publication to 2002 IEEE International Conference on Robotics and Automation, Washington D.C.