Robotics

• Robot


  A device that has been programmed to perform specific tasks
• Surgical robots


  Different from ordinary robots as they are controlled by the surgeon unlike other robotic machineries wherein the robots are automated, meaning they are programmed
• Surgical Robots


  • Computer-enhanced surgical devices
  • Controlled entirely by the surgeon
  • Purpose of improving performance and improve the outcome
• AESOP


  • Automatic Endoscopic System for Optimal Positioning
  • 1ST computer-assisted surgical device
  • Intended for the easier maneuverability of endoscope
  • Enables the surgeon to maneuver the laparoscope either with a hand control, foot control or voice activation
• Aesop (620-560 BC) was a Greek fabulist who promoted Anthropomorphism
• ZRSS


  • Zeus Robotic Surgical System
  • Not only confined with maneuvering the endoscope but can also hold retractors and laparoscopic instruments
• Advantages of Surgical Robots


  • Reduction in operative time
  • Steadier image
  • Reduction in the number of required laparoscope cleanings
  • Eliminating the need for a human camera holder
• This technology has now been eclipsed by simpler systems using passive positioning of the camera with a mechanical arm but the benefits of a steadier image and fewer members of the OR team remain
• Master-slave Surgical Platform


  • Master: Surgeon
  • Slave: Robot
• The robotic surgeon is seated on a console while the video camera and the arms are inside the patient and these are controlled by the master console
• Ergonomically Comfortable Work Station


  For the surgeon
• 3D Imaging


  Gives the surgeon more accuracy and information about the depth of the surgical field compared to conventional laparoscopic surgery
• Tremor Elimination


  • Includes the additional range of motion of the robotic arm
  • Tremors from humans can be reduced by the robotic arm
• Scaling of Movement


  Large, gross hand movements can be scaled down to allow suturing with microsurgical precision
• The most recent iteration of the platform features a second surgical console enabling greater assisting and teaching opportunities
• The surgeon is physically separated from the operating table
• The working arms of the device are placed over the patient being assisted by the surgical assist responsible in replacing the tip of the robotic arm depending on the necessity during the procedure
• Docking


  Placement of the robotic working arm to the patient/surgical field
• Disadvantages of Surgical Robots


  • Skepticism by the expert laparoscopists
  • Longer preparation and more expensive equipment
  • Additional quality could not be demonstrated
  • Operative time was longer
  • No difference in ultimate outcome
  • There is no haptic feedback
• The use of robots does not guarantee a better outcome
• There is no haptic feedback, the feeling of touching something is absent
• Applications


  • Increased dexterity – more refined movement, tremors are eliminated
  • For marketing purposes
  • Cardiac surgery and migrated to the pelvis (surgeries known for having limited fields)
  • Cardiac: Mitral valve surgery
  • Thyroidectomies
  • Colectomies
  • Advantages demonstrated only very sparingly
  • Increased cost and operative time challenge the notion of "better"
• Minimally Invasive Urologists


  • Declared that robotic prostatectomy is preferable
  • Ability to visualize and spare the pelvic nerves responsible for erectile function
  • Creation of the neocystourethrotomy
• Female Pelvic Surgery


  • Reaching wide appeal
  • Microsurgical task
  • Re-anastomosis of the Fallopian Tubes
• General Surgery


  • Revisional Bariatric Surgery
  • Complex Abdominal Wall reconstruction
• Comfort


  The surgeons are given the most comfort as they can sit comfortably and perform the procedure remotely through the robotic arms
• Telesurgery


  • Surgeon is at great distance from the patient
  • Rarely been used due to safety issues
• Laparoscopy vs Robotic Surgery


  • Wrist Movement
  • Laparoscopic Surgery: In-out, Pitch (up-down), Yaw (left-right), Rotation of shaft (Clockwise-counterclockwise)
  • Robotic Surgery: In-out, Rotation of shaft (Clockwise-counterclockwise), External Pitch (up-down), External Yaw (left-right), Internal Yaw, Internal Pitch
• Natural Orifice Transluminal Endoscopic Surgery (NOTES) aims to avoid scars and pain caused by abdominal wall trauma
• NOTES


  • Flexible with endoscope
  • Observation through GI, urinary, reproductive tracts
  • Traverse the lumen into the peritoneal cavity, the mediastinum, or the chest
• Transiluminal Surgery


  • Usually used in the stomach
  • From the inside out: Percutaneous endoscopic Gastrostomy
  • From the outside in: Laparoscopic-assisted intragastric tumor resection
• Catalyzing events for NOTES include procedures where there is a collaboration between a surgeon and a gastroenterologist, performance of cholecystectomy transorally via NOTES in porcine gallbladder, and a series of 10 human appendectomy cases from India
• Challenges of NOTES


  Safety of transluminal access
• Mediastinum


  The chest
• Transiluminal surgery


  • Usually used in the stomach
  • From the inside out
• Transiluminal surgery


  • Percutaneous endoscopic Gastrostomy
  • Entrance into the mouth (natural orifice)
  • A method of placing a tube into the stomach percutaneously, aided by endoscopy
• Transiluminal surgery


  • From the outside in
• Transiluminal surgery


  • Laparoscopic-assisted intragastric tumor resection
• Catalyzing events


  1. Procedure where there is a collaboration between a surgeon and a gastroenterologist

  2. Porcine gallbladder

  3. Performance of cholecystectomy transorally via NOTES

  4. Appendectomy: series of 10 human cases from India
• Challenges of transiluminal surgery


  • Safety of transluminal access
  • Entry (e.g. mouth) and involvement of a non-pathologic/physiologically organ/structure and perform a procedure such as appendectomy or cholecystectomy
  • Limitations in equipment
  • Equipments used are not readily available
  • Expensive