Robotic Surgery – An Overview

Dr. VIRAL PATEL
Consultant, Gynecologic Oncology,
HCG Aastha Cancer Centre, Ahmedabad

Figure 1: Patient cart is seen with 4 robotic arms attached to an overhead boom. The robotic arms are covered with sterile drapes I preparation for surgery
Figure 2: Helm of the patient cart with the power switches , driving controls and a touch pad which allows site selection before surgery
Figure 3: Surgeon console showing the stereo viewer, master controllers (enlarged in the inset picture), foot pedals and arm rest

An over view of robotic surgery

Introduction:

Using robots for surgery began with the development of ‘Aesop’ and ‘Zeus’ by Computer motion Inc. California. It was Intuitive Surgicals Inc. Sunnyvale, California that made surgical robots popular and safer with their daVinci robot. From the first three arm ‘standard’ version to the latest ‘daVinci Xi’ and single port ‘daVinci sp’ systems, the robotics in surgery have come a long way. Multiple specialties like urology, gastro surgery, cardiac surgery, thoracic surgery and head and neck surgery are making use of robotic technology in addition to gynecologists. In gynecology, robotic assistance can be of help in hysterectomies, surgery for endometriosis, myomectomies and also for pelvic sidewall surgeries
and sacrocolpopexy. Minimally invasive surgeries became popular in the field of gynecologic oncology with the advent of robotic assistance. The new da Vinci Xisystem with fluorescent capabilities and overhead boom enabling easy multiquadrent access is of great help in oncosurgery. Technology has improved human life and the field of surgery is also being helped by technology by aiding
human eyes to see better and helping our hands perform more precise and intricate surgeries.

Robotic Instruments and Machine
Most commonly used robotic system around the world is the daVinci robotic System. The latest versions are the daVinci Xi system launched in -2014 and the daVinci sp system launched in 2018. There is a also a daVinci X system launched in 2017 which is a hybrid between the da Vinci Si and Xi system. There are
three main components for any robotic system: i) Patient cart, ii) Surgeon console and iii) Vision cart. In addition to these there are the 0 degree and 30 degree robotic cameras, robotic surgical instruments, and the trocars used for instrument insertion.

Patient cart
This is the part of the robotic system that is close to the patient. It has a base andcolumn attached to it. The robotic arms are attached to the column directly in the older versions and X version, but the Xi version has an overhead boom attached to the column and the arms arise from the boom (fig 1). This modification helps the Xi system to have more flexibility and allows for multi-quadrant surgery, as
the boom can be rotated 360 degree. The patient cart is motor driven with a helm, which allows the technician to control and move the patient cart. The helm has a touch pad which allows the technician to select the area of surgery (e.g. pelvis, upper abdomen, renal etc.) and the position of the robotic arms are
aligned according to the selection. (Fig 2) There is also a microphone and speakers inbuilt in the robotic boom to enable the patient side assistant to communicate with the surgeon. The four robotic arms are attached to the boom. In contrast to the older versions of daVinci, where there was a fixed camera arm, Xi and X systems have universal arms, which allows camera to be inserted into any of the arms. This camera hopping is an advantage during complicated surgeries allowing for better. visualization and instrumentation. Before surgery the arms and column are covered with disposable sterile surgical drapes (fig 1) Sp system has flexible instruments that can be put through a single port and allows single quadrant surgery. It is ideal for gynecologic surgeries and allows virtually scarless surgery if done through umbilicus.

Surgeon Console
Surgeon console is the place where surgeon sits and controls the instruments and camera to perform surgery. It has four major parts. 1) Stereo viewer through which surgeon visualizes the surgical field in a 3 dimensional manner, 2) master controllers which helps surgeon to control instruments and camera, 3) foot pedals which have energy activation switches and also helps to swapinstruments and control camera 4) Arm rest on which surgeon rests the arms during surgery. Power and emergency stop switches are located on the right side of the armrest. On the left side there are a set of ergonomic switches with which
the surgeon can optimize the height and tilt of the console. In the middle of the armrest there is a touch pad that shows the list of instruments used, the energy settings, camera toggle, and also the advanced settings of the robot like tile pro and firefly.

There are many inbuilt safety mechanisms within the surgeon console. The instruments will be activated only when the surgeon sits and rest his/her head in the stereo viewer and activate the infrared sensors. If the surgeon’s head is lifted the instruments and camera in the field will freeze in their positions. The master control also will be activated only when the surgeon’s fingers are gripping on the masters. Any other movement will not activate the instruments. Master controllers also have the ability to filter the minute tremors of the surgeon’s hands. Movements of master controller can be adjusted to normal, fine and quick depending on surgeon preference and type of surgery. Surgeon on the console communicates with the surgical team near the patient through the mike and speakers set on the stereo viewer.

Vision cart
This is a tower similar to the laparoscopic cart with the following parts Touchscreen monitor: patient side surgical team can view the surgery through this monitor. It also allows for teaching a novice by telestration (drawing on the screen, thus guiding surgical dissection). (Fig 4). The monitor also displays the number of uses remaining for an instrument, which instrument is on use in each arm, which type of camera is being used (fig5) and displays guided set up. Guided set up is the way the system guides the nursing team to prepare the patient cart for surgery. In case of any error in the system, messages detailing the fault and corrective action to be taken will be displayed on the monitor. Diathermy: da Vinci xi and X vision carts have an integrated Erbe system as the diathermy source Endoscopic controller: Connects Endoscopic camera. Also has provision of capturing high definition still pictures during surgery. Shelf for other equipments : Insufflators and harmonic diathermy can be integrated in these shelves

Trocars, instruments and Drapes 

Trocars: Comprises stainless steel cannulas, with a plastic seal and obturator . All the trocars of da Vinci X and Xi system are of 8 mm in diameter. The plastic cannula seal is disposable and is of 5-8 mm which
also allows insertion of 5 mm laparoscopic instruments without CO2 leak. The cannula has a remote center which is outlined as a black band in between two black lines. For optimum use, the remote Center must be placed on the abdominal wall thus minimizing the tension. (fig 6)

Instruments: (Fig 7) robotic instruments has three parts: Jaws, shaft and base. The base has levers that help attach and detach the instrument on the robotic arm. There are discs on the base that are attached to metallic wires, which go through the shaft and are attached to the jaws. The Jaws are moved with the help of pulley action of these disc and wires. There are more than 30 different robotic instruments available for surgery. The
instruments are finer compared to traditional laparoscopic instruments. Main instruments for gynecologic surgery are prograsp – used for retraction and tissue traction, hot shears (monopolar scissors), fenestrated or maryland bipolar forceps and needle driver. Finer instruments and the seven degrees of motion of the instruments are the main advantages of robotic over laparoscopic surgery

 Drapes: these are sterile disposable plastic covers which are used to cover
the robotic arms and column to make the patient cart sterile before
surgery (fig 1)

Robotic Surgery in Gynecologic Oncology
Traditionally surgeries for malignancies were always done through large abdominal incisions. Even with the advent and popularity of minimally invasive surgeries (MIS), oncosurgeons were reluctant to convert to MIS doubting the ability of MIS to completely remove tumor. Randomized controlled trials have shown that MIS for endometrial cancer has similar oncological outcomes with decreased morbidity. The steep learning curve of laparoscopy limited use of MIS by gynecologic oncosurgeons. Introduction of robotics made surgeons around the world adopt MIS for endometrial cancer with good clinical outcomes . Complex procedures like pelvic and para aortic lymphadenectomy, which are required for staging endometrial cancer, could be easily performed with robotic assistance. Robotic surgery in addition to improving short term morbidity, can also improve long term morbidity in patients with endometrial cancer Sentinel node mapping is another technique that reduces the surgical morbidity of lymph node dissection while giving accurate prognostic and staging information. The most sensitive technique for sentinel node mapping is using Indocyanine Green dye (ICG) followed by near infrared (NIR) imaging. The inbuilt NIR imaging capacity of davinci Xi system made robotic sentinel node mapping one of the most sensitive techniques to detect sentinel node in endometrial cancer (Fig 8). In our experience of over 250 patients who underwent sentinel node mapping for endometrial cancer, the technique showed
97.8% sensitivity in detecting a sentinel node. Pelvic and para aortic lymphadenectomy may be required in case of failed sentinel node detection or in case of enlarged nodes. 

Advantages and Disadvantages of of robotic assisted surgery
Robotic assisted surgery has the advantages of shorter learning curve, finer instruments and 3 –D camera with better surgeon ergonomics allowing surgeon to do surgeries with great precision. Latest versions also have inbuilt infrared system which allows the visualization of fluorescence from Indocyanine green dye, which helps in sentinel node mapping. Tile pro is another feature in in
the daVinci system, which allows images from ultrasound or CT scan to be incorporated into the screen.
Lack of haptics is one of the disadvantages of robotic assisted surgery. But this is compensated to a great extent by the enhanced vision. Cost is another major drawback. In addition to the initial cost of procuring the robotic platform, there is recurring cost for the instruments and also maintenance costs. Each instrument per use incurs a cost of 18,000 to 20,000 rs and they only have a fixed number of lives after they need to be replaced. This increased cost is the major reason why in spite of the greater precision and shorter learning curve, robotics is not being used widely in India. But in spite of the increased cost of surgery, patients can save cost on other aspects when robotic assisted surgery is used. The faster recovery allows for shorter hospital stay and also decreased use of intravenous fluids, analgesics and antibiotics which indirectly results in cost saving .

Training new robotic surgeons
The learning curve of using a technical instrument should not put the patients at jeopardy. Risks can be reduced and learning could be improved through a structured learning pathway including e-learning, virtual reality simulations, case observations, dry, wet and cadaveric lab training and finally experienced surgeons proctoring the new surgeons. Robotic surgery has a very structured learning program incorporating the elements of the above-mentioned pathway, which even senior experienced surgeons need to undergo when starting robotics.

Future
Many new companies are on the brink of bringing in new versions of surgical robots and in future we may see the costs reducing. There are prototypes where haptics is incorporated, some versions seems to have detachable arms offering more flexibility. Remote surgey although technically possible even now, is currently not being practiced. But in future we may see surgeons operating on patients located in another city or in another country.Artificial intelligence is still not incorporated into gynecologic robots, but as technology is advancing that is also a possibility

Figure 4: Vision cart showing the monitor, integrated diathermy and vision system
Figure 5: touch screen monitor displaying the instruments used, uses remaining for each instrument and other settings
Figure 6: Remote center placed at the abdominal wall

Figure 7: The 4 common instruments used for gynecologic surgery. The base, shaft and jaws are seen. The upper left hand side of the picture shows the discs. Inset picture shows the size of the jaw of a
prograsp forceps

Figure 8: Right external iliac Sentinel Lymphnode(SLN) seen under NIR imaging