Robotic surgery has allowed surgeons to perform complex procedures with improved precision, flexibility and control. The advent of robotic surgery began in 1985 when the Puma 560, developed by Victor Scheinman at Unimation, was used to perform neurosurgical biopsies. This method of surgery was used to improve precision as it eliminated the hand tremors of surgeons which could cause error during needle placement. Subsequently, in 1988, the Puma 560 was for the first time used to perform a transurethral resection of the prostate, a more complex procedure. The success of the resection as well as neurosurgical biopsies caused an increase in demand for robot-assisted surgery and led to the development of the ROBODOC surgical system by Integrated Surgical Supplies Ltd. ROBODOC became the first surgical robot to be approved by the FDA.
With newfound excitement in robot technologies, the U.S. Army provided funding to devise a system that could be operated remotely, hoping that this new technology would decrease wartime mortality by eliminating the transportation time of wounded soldiers in need of surgery. The devised system was tested on animal models but never proceeded to being used in the battlefield. After redesign, this system was reintroduced as the da Vinci Surgical System by Intuitive Surgical Systems. This minimally invasive robotic surgical system was approved by the FDA in 2000 and is currently the only robotic surgical system used in the U.S.
The da Vinci system has three essential components:
- A vision cart that holds a dual light source and dual 3-chip cameras.
- A master console where the operating surgeon sits.
- A moveable cart, where the three instrument arms and the camera arm are mounted in the S and SI system.
The vision cart is the brain of the da Vinci as it acts as the central computer. Each video chip that is contained in the vision cart is designated for one eye, allowing for a 3D image. The camera can be placed on any of the arms and contains both white and U.V. light sources. The U.V. light allows surgeons to see indocyanine green, which can be used to target cancer cells, particularly small tumors.
The master console contains an image-processing computer that generates a 3-dimensional image with depth of field. This 3-dimensional image is displayed above the hands of the surgeon, providing an illusion that the instruments are extensions of the control grips. It also contains the view port where the surgeon views the image, the foot pedals which control electrocautery, the camera focus, the instrument/camera arm clutches and the master control grips that drive the servant robotic arms at the patient’s side. The instruments provide seven degrees of freedom which allows for endowrist manipulation providing full rotation like that of a human hand. The master console has a motion sensor at forehead level which allows the system to automatically shut off movement in the robot arms if the surgeon’s head is not in place.
The da Vinci system provides many advantages that exceed even those provided by laparoscopic surgery tools. The use of this robotic surgical system improves visualization and allows for increased dexterity. This allows access to previously remote parts of the body which cannot be reached with the limitations of the human arm. In addition, the system reduces the surgeon’s operating time spent on reaching difficult areas of the body, thereby reducing the surgeon’s fatigue. Furthermore, the robotic arms circumvent any blood loss caused by tremors from the surgeon’s hands. The surgical system also reduces pain and post-op complications because the trocar sites are only 8 mm and can be closed using glue, eliminating the need for sutures. The da Vinci also reduces the surgery team as only three people — the surgeon, scrub tech assist, and resident — are required to operate it.
The da Vinci system is currently being used for several laparoscopic surgeries. In addition, the vast majority of prostate cancer surgeries in the United States are done with the aid of the da Vinci system. One study by Cadière et al. has shown that the system was most useful in intra-abdominal microsurgery and manipulations in very small spaces. In addition to this, many studies have been conducted showing that robotic surgery is safe for gynecologic procedures.
Robotic surgery has transformed minimally invasive cardiac surgery. The most noteworthy application of the da Vinci system is endoscopic coronary grafting. This procedure was previously not achievable through laparoscopic means. A study by Kappert et al. showed that endoscopic coronary bypass surgery has favorable short-term outcomes by successfully constructing left internal thoracic artery (LITA) to left anterior descending (LAD) artery anastomoses on 17 of 19 patients. In addition, the study demonstrated that robotic endoscopic mitral valve repair was possible by successfully performing robotic mitral valve repair in 14 of 17 patients. Another extensive application of the robotic surgical system is in pediatric laparoscopic surgery. Pediatric laparoscopic surgery is limited by the fact that anastomoses cannot be done to a precision of 2 to 15 mm by standard laparoscopic tools. However, this can be accomplished through the use of the da Vinci system.
Despite its many advantages, the da Vinci system also poses some limitations. Robotic surgery is quite a recent invention and its full consequences are not yet recognized. The main disadvantage of the da Vinci system is simply the cost of the machine. The da Vinci system costs up to $2 million, which greatly reduces its availability and use. In addition, the machine itself is extremely large. This makes it cumbersome to have in surgical rooms that are filled to the brim with a surgical team and other equipment. Additionally, most surgeons do not have the training and experience necessary to fully utilize a system that requires a unique and specific skill set.
Apart from the cost and training, there are also technology limitations, such as latency and the ability to change course during surgery. Latency refers to the time lapse between the moments when the physician moves the controls and when the robot responds. Also, there is still a chance for human error if the physician incorrectly programs the robot prior to surgery. Computer programs cannot change course during surgery, whereas a human surgeon can make needed adjustments. There are also potential cybersecurity risks such as hacking and malware.
The need to adopt and continually update treatment protocols to reduce errors is crucial to improve patient care. Though the robotic surgical system has already been extremely beneficial, it can still be greatly improved by addressing the above limitations and adding full sensory inputs by expanding the list of compatible instruments. These changes could help make the da Vinci a truly complete, integrated and essential mainstay for surgery.
Nithyapriya Shankar is an incoming medical student at the University of Queensland-Ochsner School of Medicine. Nithyapriya graduated from the University of Houston with a Bachelors of Science in Honors Biomedical Science. Nithyapriya's previous research experiences include cardiology, maternal-fetal medicine, neuroscience and neonatology. Currently, Nithyapriya is a research assistant in the neonatology department at Baylor College of Medicine/TCH and is assisting with research on the effects of oxygen exposure on premature neonate lung development.