Robotic Surgery – All You Need To Know

Patients today prefer operations based on minimal access technique over the traditional open surgery. This is because minimal invasive techniques lead to reduced postoperative pain, lower chances of wound infections, shorter hospital stays and better cosmetic outcomes. Favourable results also motivate researchers and surgeons to attempt minimal invasive surgical procedures whenever possible. Since the 1990s, the most used minimal invasive technique was laparoscopic procedures. However, certain limitations such as instability of video camera and a limited two-dimensional vision were some of the factors that made researchers think beyond laparoscopic measures when performing surgeries ^[1] .

These limitations of laparoscopic techniques were addressed by robotic surgery. This revolutionized minimal access surgery ^[2] . Extensive study and research are being conducted to make all forms of surgeries be possible, in the future, through robotics. Apart from the procedure itself, robotic surgery would create the need for a modification to the existing surgical training pattern. This would facilitate the reshaping of the learning curve of aspiring surgeons.

What Is Robotic Surgery?

A robot that is enabled to participate in the surgical process is said to be self-powered. It is a computer-controlled device that is programmed in such a manner that it aids the positioning and manipulation of surgical instruments. Such devices enable the surgeon to carry out tasks that are complex in nature ^[3] . These devices do not act independently (that is replacing human surgeons), but instead work as remote extensions that are governed by the surgeon-in-charge. The working of the robotic devices alongside the surgeon is quite often called 'master-slave manipulators' ^[4] .

Till date, there are two such master-slave robotic systems that have received approval from the US Food and Drug Administration (FDA) ^[5] :

1. the da Vinci Surgical System ^[6]
2. the ZEUS system ^[7]

The robotic systems have two basic components linked together with a computer using data cables ^[8] .

1. The surgeon's master console

The robot's user interface is the surgeon's master console. The master (surgeon) can attain the following information from the user interface ^[9] :

• View of the master manipulators - This has the handles/joysticks which helps a surgeon make surgical movements. These virtual movements are then translated into real-time surgical movements through the slave manipulators that are docked on the patient. Use of such manipulators make motion scaling ^[10] (large movements are converted into ultraprecise micromovements) and tremor filtering ^[11] possible. This facilitates the increase of precision and accuracy of the surgeon's movements.
• An endoscopic camera that is inside the patient's body controls the robot and provides a three-dimensional view of the surgical field. The gives a better and immersed view of the surgical field to the surgeon.
• The existing control panel helps with functions such as camera focusing, provision of accessory units and motion scaling.

2. Patient-side slave robotic manipulators ^[12]

Robotic arms are connected to the patient's body. These arms are designed to manipulate the surgical instruments and the camera with the help of the laparoscopic ports. The da Vinci system possesses micro articulations near the tip that handles surgical instruments. This is designed to duplicate the motions of the human wrist.

Advantages Of Robotic Surgery ^[13]

Compared with traditional techniques, many surgeons vouch for the attributes and ease of operation that robotic surgical procedures offer.

The following are some of the benefits of robotic surgery:

• Precision enhancement
• Improved flexibility and control during the surgery
• A better view of the surgical site
• Assists better performance of delicate and complex procedures (some of which are highly difficult using traditional methods)
• Reduced complication (surgical site infection)
• Minimal blood loss and reduced pain
• Less tissue damage
• Smaller scars that are less noticeable
• Quick recovery

Most Common Operations Performed Via Robotic Surgery ^[14]

The following is a list of the current fields that extensively observe robotic surgeries.

1. Robotic gastrointestinal surgery

• Heller's myotomy
• Gastrojejunostomy
• Antireflux operations
• Gastric bypass
• Esophagectomy
• Splenectomy
• Gastric banding colectomy
• Pancreatic resection
• Adrenalectomy

2. Robotic urologic surgery:

• Radical robotic prostatectomy is the most common type of robotic surgery.

3. Robotic gynecologic surgery:

• Salpingo-oophorectomy
• Microsurgical fallopian tube reanastomosis
• Hysterectomy

4. Robotic cardiothoracic surgery

• Robots allow complex cardiothoracic procedures such as
• mitral valve repairs,
• pericardiectomy, lobectomies,
• tumour enucleations, and
• atrial septal defect repair.

5. Robotic oncologic surgery

• Gastric cancer
• Colon cancer
• Retro mediastinal tumours
• Oesophageal tumours
• Thymoma

6. Robotic pediatric surgery

• Antireflux procedures for gastroesophageal reflux disease
• Pediatric congenital heart diseases
• Pyeloplasty for ureteropelvic junction obstruction

Limitations Of Robotic Surgery ^[15]

There are a few limitations that prevent robotic surgical techniques from achieving its complete potential. The following are some of the disadvantages of robotics in the field of surgical procedures:

• Cost-effectiveness

The major issue lies with the costs involved in terms of purchasing the robot and its yearly maintenance. However, this aspect is believed to be sorted in the near future as robotic systems gain more acceptance. Also, a decrease in hospital stay and operative time will make robotic surgery cost-effective.

• Bulky robotic equipment

Most of the present day robotic equipment is heavy and bulky making it difficult for the setup of the surgical procedure.

• Lack of tactile feedback to the surgeon

Most of the time, the surgeon misses out on receiving tactile and force feedback from the robotic manipulators used. The ideal solution for this would be the use of haptics (systems designed to recreate the feeling of tissues via force feedback), which is likely to be the recognized solution in the near future.

Training Of Robotic Surgery To Medical Students

Surgical training has been following a more or less same structure for almost a century (at least until robotic surgery came into existence). Surgeons undergoing training had to gain operative experience through supervised trial and error methods on real patients. The cons of this approach would be compromising the patient's safety, prolonging surgical training and training dependent on the actual load of the case.

Robotic surgery has paved the path for acquiring surgical skills from means of simulating operations that can be done via a robot. Operations can be practised by using surgical robots. Simulations can be performed on three-dimensional, virtual-reality and soft-tissue models (which recreate the textures of human tissues through haptics) ^[16] .

Prior to operating on a patient, three-dimensional reconstructions of the anatomy of the patient under observation can be used to practice procedures and plan the operation. This is made possible through image-guided simulations. Telementoring ^[17] can be used to guide trainees during these simulations.

Using these techniques ensures that trainees acquire surgical skills sooner. This practice also helps in improving the safety of the patient by reducing the chances of surgical errors. The overall learning curve of the would-be surgeon is enhanced through robotic surgery training.

Is Robotic Surgery Right For You?

Robotic surgery for specific ailments can involve risk, quite similar to the conventional open surgeries. It is therefore essential that you speak out and clarify the pros and cons of robotic surgery with your healthcare provider. On speaking with your doctor, you might be surprised to hear that robotic surgery might not be favourable for your health condition. The best way to reach a conclusion is to compare this technique along with other available minimal invasive surgeries and if the traditional open surgery would be a better alternative ^[18] . Also, robotic surgery might only be available in sophisticated hospitals.
[19]

How Costly Is Robotic Surgery In India? ^[19]

Robotic surgery still continues to be beyond the reach of most of the institutions and health-care system in India. The primary reason behind this is the excessive maintenance costs along with the disposable supply cost. On average, for regular procedures using robotic surgical methodologies, the ideal cost would be about Rs. 1.5 Lakh. Hospitals tend to charge more because of the high equipment cost associated with robotic surgery (which is about Rs. 15 Crore). Robotic surgeries are performed at esteemed hospitals across the country using the da Vinci robots.

On A Final Note...

Although still in its emerging spree, robotic surgery is surely one of the cutting-edge, finest development in the field of medical science. With proven far-reaching implications, robotic surgery ensures precision and dexterity improvement. This technology has allowed surgeons to perform surgeries that might not have been possible using traditional techniques.

Robotic surgery makes way for utmost patient safety and has shown several favourable outcomes. This technique allows minimal access surgery to be applicable to a wide range of procedures.

However, there is a need for controlled trials to identify the pros of robotic-assisted procedures alongside laparoscopic and other open techniques. The issues related to cost, clinical effectiveness and technical drawbacks need to be addressed ^[20] so that robotic procedures can be brought into the mainstream to reshape how surgical practice is conducted.