by Justina Hurley
What is robotic surgery?
Robotic surgery has been around now for over fifteen years, but there is still some confusion in people’s minds as to what robotic surgery actually means.
The system currently used worldwide is called the Da Vinci Robot. This is essentially a piece of equipment that is made of two parts. The first is the robotic instrument, which is a machine with five arms that can hold specialized instrumentation, including: a miniaturized surgical camera, wristed scissors, scalpels and forceps – all designed to help with delicate dissection and reconstruction deep inside the body.
The second and most important part is the console at which the surgeon sits. From there the surgeon has full control of the robotic arms and, in addition, via the console has high-definition 3D vision and a magnified view.
This is not iRobot or AI style robotics! At no time can the robotic part act on its own. It is in reality a type of operating equipment that is remotely controlled by the surgeon at all times. Should the surgeon stop or need to stop operating at any time, the robot automatically stops.
To find out more about robotic surgery we spoke with Dr Matt Hewitt, President of the British and Irish Association of Robotic Gynaecological Surgeons (BIARGS).
Dr Hewitt is a Consultant Obstetrician and Gynaecologist who is subspecialty-trained in Gynaecological Oncology Surgery and Colposcopy. Based in Cork University Maternity Hospital (CUMH), he is the most experienced gynaecological robotic surgeon in the UK and Ireland and has been using the Da Vinci Surgical Robotic System since 2008.
The ultimate virtual reality game?
It has been said that performing robotic surgery is not too dissimilar to playing a virtual reality computer game. But is that true? According to Dr Hewitt:
The 3D view and sense of being immersed inside the patient with the increased field of view is quite remarkable. I have now performed over 350 robotic cases but still enjoy the experience of using the equipment. The surgeon experiences less frustrating episodes during a surgical procedure compared with conventional keyhole surgery. A happy surgeon is a safe surgeon.
I allow the students to briefly look down the console while I am operating and they are always quite amazed by the view of the surgery that is achieved.
So to answer the question of this being a virtual reality game, in some ways it is, but more realistic than anything available to buy in a games shop. One of course always has to remember that patient safety is paramount.
How does DaVinci surgery differ from keyhole surgery?
In reality, robotic surgery is a form of keyhole surgery. In all keyhole or minimally invasive surgery there are advantages such as:
- Less pain postoperatively
- A quicker recovery
- A shorter hospital stay
- Smaller scars which are more aesthetically pleasing to the patient
- Reduced infections
- Reduced blood loss and reduced need for transfusion
- Reduced scarring
Robotic surgery offers many advantages over traditional keyhole or laparoscopic surgery.
In robotic surgery, from one to five small incisions (each approx 1cm) are made and hollow tubes called trochars are then positioned inside the patient. The specialised instruments are fed through these tubes and held in position by the robot. The instruments are then controlled by the surgeon from the console which is operated by hand controls and a foot pedal. A camera is also inserted and this is also operated from the console allowing the surgeon to control the camera and to zoom in and out as required.
This differs from traditional keyhole surgery where the surgeon is heavily reliant on a skilled assistant to hold the camera and other surgical instruments. The robotic camera offers 3D imaging while in standard keyhole surgery the surgeon sees the surgical field in 2 dimensions on a screen.
The robotic instruments are very flexible and offer full rotation. They also mimic the surgeons movements so if the surgeon moves to the right the instrument moves to the right. This is in contrast to laparoscopic surgery where there is a limited range of movements of the surgical instruments and the movement does not mimic the surgeon. For example, if the surgeon needs to move an instrument to the right, they have to move their hand to the left.
In addition, because the robot is actually holding the instruments, natural hand tremor is eliminated giving the surgeon a much greater degree of precision and control. In standard keyhole surgery, the fact that the surgeon holds the instruments and is standing throughout the operation can lead to surgeon fatigue.
Dr Hewitt and his team at the CUMH conducted a review of the Da Vinci system* and found that for all the reasons given above, robot assisted surgery can overcome many of the difficulties posed by laparoscopic surgery in gynaecological procedures. Dr Hewitt comments that the main advantage is the control that the system gives to the surgeon:
To not have to rely on an assistant for the precise camera angles I need is great. Also the different sensitivity settings on the console let me choose the degree of movement of the instrument and of course being able to perform long surgeries while seated really helps to lower fatigue.
But it not just all about the surgeon. Hewitt and his team found that the real winner was the patient:
For the patient robotic surgery offers many advantages. It is quicker, reduces errors, reduces the hospital stay and results in less blood loss in comparison to open and laparoscopic surgery
Patients who undergo robotic surgery have a much better surgery and recovery experience with minimal use of pain medication, little bruising at the incision sites and no unsightly scarring. This in turn lessens the psychological trauma that can occur for patients who have had serious surgeries.
Moreover, an even greater benefit for the patient is in the very precise and delicate surgery that can be done by the robot in hard to reach areas. This kind of minimal access surgery enables experienced laparoscopic surgeons to perform more complex procedures in even in the most challenging of patients.
For example, hysterectomies, particularly radical hysterectomies for gynaecological cancers, are major operations which require intricate surgery. The precision and degree of movement that the DaVinci system offers, enables surgeons to dissect lymph nodes and operate closely to the bladder and bowel with much less risk of injury than in standard laparoscopic surgery and traditional abdominal surgery.
This offers the patient a much greater chance of emerging – especially from cancer related hysterectomies – without nerve damage or injury to the bladder or bowel, all areas which are very vulnerable to injury during such procedures.
The findings of the Cork CUMH team are also backed up by those who use the DaVinci system for prostate surgery where robotic techniques are said to be giving better outcomes for continence and bladder control.**
There are those who question the need or value of robotic surgery. They say it is expensive and not so much better than other less costly procedures. Dr Hewitt acknowledges that the Da Vinci system is expensive to purchase and to maintain, so in the short term it can seem to be an unnecessary expense. Set up times and floor space are also factors to consider as are the training requirements for specialist nursing and theatre staff. However, in assessing the system, the mistake is to compare using financial cost-based outcomes, as, what is not factored in to such outcomes is the patient’s experience along the path and the long term health of the patient post surgery. Dr Hewitt comments:
There are many experienced surgeons who can carry out complex surgery without using a robot and they would question the benefit of using a robot. From my experience I am able to undertake more complex cases robotically that I would not be able to undertake with conventional keyhole surgery. Furthermore my conversion rate (changing from a keyhole to open surgery during an operation) is much lower with robotic surgery.
We have audited our keyhole surgery hysterectomy rates compared with standard open surgery in the Cork University Maternity Hospital and the rate in the rest of Ireland. We have a much lower rate of open surgery in Cork and think this is directly related to our use of the robot.
To see Dr Hewitt demonstrating the DaVinci system by peeling a grape (!) live on an Irish television show and to hear the experience of a patient who had a robotic hysterectomy the day before, see the clip below:
In the US the DaVinci system is used for a wide variety of procedures including cardiac bypass surgery.
It was also recently used in a ground breaking heart valve reconstruction at Temple University Hospital, in Philadelphia where T. Sloane Guy, MD, MBA, Associate Professor of Surgery, Section Chief of Cardiovascular Surgery, and Chief of Robotics at Temple University School of Medicine (TUSM) became one of the first cardiovascular surgeons to perform complete tricuspid valve repair procedures endoscopically using robotic techniques.
See Dr Guy speak about his experience in the clip below:
There is also the real benefit to the patient in not having to deal with a large wound. For example, a regular heart bypass surgery involves not just a large incision but also requires the breastbone to be split to open the ribcage. When robotic surgery is used for bypass, it can be performed using just a few small incisions and no need to cut the breastbone.
Hospitals too gain in surgeon productivity, as robotic surgery leads to less surgeon fatigue and so such surgeons can potentially perform more procedures than might be possible if they were performing long laparoscopic or open surgeries.
That is not to say that robotic surgery is always flawless. As with any surgery there are risks and complications can occur regardless of the procedure used. There are detractors of this system who claim that this type of surgery is more risky than people think and allude to legal actions currently underway in the US. However closer examination of most of these cases usually points to human error and lack of surgical experience using the Da Vinci system, rather than a fundamental problem with the system itself.
The importance of training
This leads to the very important issue of surgeon training. In essence, the DaVinci robot is a piece of equipment and, as with all medical equipment used in surgical and critical care situations, it is only as good as the team maintaining and using it.With respect to training Dr Hewitt explains:
Surgeons who use the robot have all gone through basic and higher surgical training and are usually consultants i.e. qualified to operate independently
Training in Robotic surgery is quite tightly controlled and surgeons new to the robot are trained using simulators before they are allowed to operate on a patient. Furthermore they are closely supervised by an experienced robotic surgeon before they operate solo.
The robot is 100% operated by a surgeon, so the experience of the surgeon should ultimately be the deciding factor for any patient facing surgery where robotic surgery is an option. Patients should be informed and not be afraid to ask about the surgeon’s track record and what training they have had to date.
To have the option of robotic surgery is a huge advantage for patients both in terms of lessening the trauma when facing a major operation and in recovery time post-surgery.
However, not every procedure suits every patient and the surgeon is the person best placed to know which type of surgery is suited both to the patient and to condition requiring surgery. A good surgeon will explain all the options and recommend the one they feel best suits you.
As great as it is, if robotic surgery isn’t an option for you for whatever reason, it’s important to remember that at the end of the day, all of this technology is still just equipment and all surgery, whether open, laparoscopic or robotic is dependant on the skill of the surgeon.
* Hewitt M, O’Carroll M, O’Reilly B. (2011) Robot-assisted surgery in gynaecology. The Obstetrician & Gynaecologist 2011;13:183–188.
** Patel et al., (2010) Continence, potency and oncological outcomes after robotic-assisted radical prostatectomy: early trifecta results of a high-volume surgeon. BJU International, 106: 696–702.
For more information on Dr T. Sloane Guy see: www.roboticheartsurgeon.com
A great resource on the history of robotic surgery and an overview of all the robotic systems developed to date can be found at allaboutrobotic surgery.com