Robot-assisted surgery

Robot-assisted surgery
Laproscopic Surgery Robot.jpg
A robotically assisted surgical system used for prostatectomies, cardiac valve repair and gynecologic surgical procedures
Other namesRobotically-assisted surgery

Robotic surgery are types of surgical procedures that are done using robotic systems. Robotically-assisted surgery was developed to try to overcome the limitations of pre-existing minimally-invasive surgical procedures and to enhance the capabilities of surgeons performing open surgery.

In the case of robotically-assisted minimally-invasive surgery, instead of directly moving the instruments, the surgeon uses one of two methods to administer the instruments. These include using a direct telemanipulator or through computer control. A telemanipulator is a remote manipulator that allows the surgeon to perform the normal movements associated with the surgery. The robotic arms carry out those movements using end-effectors and manipulators to perform the actual surgery on the patient. In computer-controlled systems, the surgeon uses a computer to control the robotic arms and its end-effectors, though these systems can also still use telemanipulators for their input. One advantage of using the computerized method is that the surgeon does not have to be present, but can be anywhere in the world, leading to the possibility for remote surgery.

Laparoscopic procedures are considered a form of minimally-invasive surgery. Several small incisions, called keyhole incisions, are made. These types of surgeries are associated with shorter hospital stays than open surgery, as well as less postoperative pain and scarring and lower risks of infection and need for blood transfusion.[1]

In the case of enhanced open surgery, autonomous instruments (in familiar configurations) replace traditional steel tools, performing certain actions (such as rib spreading) with much smoother, feedback-controlled motions that could be achieved by a human hand. The main object of such smart instruments is to reduce or eliminate the tissue trauma traditionally associated with open surgery without requiring more than a few minutes' training on the part of surgeons. This approach seeks to improve open surgeries, particularly cardio-thoracic, that have so far not benefited from minimally-invasive techniques.

Robotic surgery has been criticized for its expense, with the average costs in 2007 ranging from $5,607 to $45,914 per patient.[2] This technique has not been approved for cancer surgery as of 2019 with concerns that it may worsen rather than improve outcomes.[3]

Comparison to traditional methods

Major advances aided by surgical robots have been remote surgery, minimally invasive surgery and unmanned surgery. Due to robotic use, the surgery is done with precision, miniaturization, smaller incisions; decreased blood loss, less pain, and quicker healing time. Articulation beyond normal manipulation and three-dimensional magnification help to result in improved ergonomics. Due to these techniques, there is a reduced duration of hospital stays, blood loss, transfusions, and use of pain medication.[4] The existing open surgery technique has many flaws like limited access to the surgical area, long recovery time, long hours of operation, blood loss, surgical scars, and marks.[5]

The robot's costs range from $1 million to $2.5 million for each unit[2], and while its disposable supply cost is normally $1,500 per procedure, the cost of the procedure is higher.[6] Additional surgical training is needed to operate the system.[7] Numerous feasibility studies have been done to determine whether the purchase of such systems are worthwhile. As it stands, opinions differ dramatically. Surgeons report that, although the manufacturers of such systems provide training on this new technology, the learning phase is intensive and surgeons must perform 150 to 250 procedures to become adept in their use.[2] During the training phase, minimally invasive operations can take up to twice as long as traditional surgery, leading to operating room tie-ups and surgical staffs keeping patients under anesthesia for longer periods. Patient surveys indicate they chose the procedure based on expectations of decreased morbidity, improved outcomes, reduced blood loss and less pain.[4] Higher expectations may explain higher rates of dissatisfaction and regret.[7]

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 as 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.[8] Laparoscopic camera positioning is also significantly steadier with less inadvertent movements under robotic controls than compared to human assistance.[9]

There are some issues in regards to current robotic surgery usage in clinical applications. There is a lack of haptics in some robotic systems currently in clinical use, which means there is no force feedback, or touch feedback. Surgeons are thus not able to feel the interaction of the instrument with the patient. Some systems already have this haptic feedback in order to improve the interaction between the surgeon and the tissue.[10]

The robots can also be very large, have instrumentation limitations, and there may be issues with multi-quadrant surgery as current devices are solely used for single-quadrant application.[11]

Critics of the system, including the American Congress of Obstetricians and Gynecologists,[12] say there is a steep learning curve for surgeons who adopt the use of the system and that there's a lack of studies that indicate long-term results are superior to results following traditional laparoscopic surgery.[6] Articles in the newly created Journal of Robotic Surgery tend to report on one surgeon's experience.[6]

A Medicare study found that some procedures that have traditionally been performed with large incisions can be converted to "minimally invasive" endoscopic procedures with the use of the Da Vinci Surgical System, shortening length-of-stay in the hospital and reducing recovery times. But because of the hefty cost of the robotic system, it is not clear that it is cost-effective for hospitals and physicians despite any benefits to patients since there is no additional reimbursement paid by the government or insurance companies when the system is used.[6]

Complications related to robotic surgeries range from converting the surgery to open, re-operation, permanent injury, damage to viscera and nerve damage. From 2000 to 2011, out of 75 hysterectomies done with robotic surgery, 34 had permanent injury, and 49 had damage to the viscera.[citation needed] Prostatectomies were more prone to permanent injury, nerve damage and visceral damage as well. Very minimal surgeries in a variety of specialties had to actually be converted to open or be re-operated on, but most did suffer some kind of damage and/or injury. For example, out of seven coronary artery bypass grafting, one patient had to go under re-operation. It is important that complications are captured, reported and evaluated to ensure the medical community is better educated on the safety of this new technology.[13]

There are also current methods of robotic surgery being marketed and advertised online. Removal of a cancerous prostate has been a popular treatment through internet marketing. Internet marketing of medical devices are more loosely regulated than pharmaceutical promotions. Many sites that claim the benefits of this type of procedure had failed to mention risks and also provided unsupported evidence. There is an issue with government and medical societies promotion a production of balanced educational material.[14] In the US alone, many websites promotion robotic surgery fail to mention any risks associated with these types of procedures, and hospitals providing materials largely ignore risks, overestimate benefits and are strongly influenced by the manufacturer.[15]

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