Robotic Surgery – how far has it come?

In October 2012, a 25 year old mother became the first person in the UK to undergo minimally invasive heart surgery using the da Vinci robotic system. A day later, a builder underwent a robotic mitral valve repair in the same hospital, New Cross, in Wolverhampton. More invasive heart surgery would have resulted in greater scarring, more pain and a recovery period of months rather than weeks. Less than a month after these pioneering surgeries, the Chancellor of the Exchequer praised the expanding role of surgical robotics in a speech to the Royal Society and challenged Britain’s scientists to lead the world by developing cutting edge robotics which he pledged to support.
In conventional laparoscopy, an endoscope and surgical instruments are inserted into the abdomen through small incisions and manipulated to perform procedures. These incisions heal more quickly than the larger incisions made in open surgery. However, laparoscopy is not perfect. The instruments are restrained by a restricted range of motion, known as 4 degrees of freedom. Additionally, surgeons only have a 2D view of abdominal structures. The corollary of these difficulties is that complex surgeries such as laparoscopic gastrectomy can only be performed by a few experienced laparoscopic surgeons. These limitations demonstrate the need to simplify surgical techniques using robotics.
It is hoped that robotics will ensure a greater number of surgeons will be capable of performing complex procedures. The only commercially available robot for abdominal surgery is the da Vinci surgical system which provides 3D magnification and 7 degrees of freedom that duplicates a surgeon’s hand movements. The surgeon manipulates the four arms of the robot using foot pedals and hand controllers. Motion scaling dictates that for every 5 inches the surgeon moves the manipulators, the robotic arms only move 1 inch inside the body cavity. This ensures precise movements and eliminates hand tremor.
The da Vinci system is highly successful in prostatectomy because of the narrow confines of the pelvic cavity and the need for precision to avoid nerve damage. Similarly, robotic assistance is effective in resecting rectal cancers. In gastric cancer surgeries, surrounding lymph nodes tend to be removed but they have close proximity to crucial nerves, arteries and veins. Several groups report that robotic assistance allows this operation to be performed more safely. Similarly oesophageal surgeries risk perforating but this risk is dramatically reduced by using a robotic technique. The da Vinci robot has also been successfully used in a number of other procedures operating on the bladder, kidney, colon, throat, heart and gynaecological structures.
Robot assisted surgery has a number of advantages for patient care. These include less pain, reduced blood loss from the surgery, shorter hospital stay and faster recoveries. However, there is some doubt surgical robotics is financially justifiable.
Surgeries involving robots take longer and it is unclear whether patient outcomes are improved compared with laparoscopic techniques. The machine is also prohibitively expensive, costing £1.5 million and yearly maintenance of about £150,000. The ends of the robotic arms which grip the instruments must be replaced after 10 operations and extensive training is required before surgeons are capable of using the system. Furthermore, the bulky machine is independent from the operating table meaning that if the patient is repositioned during the surgery, the system must be un-docked and then re-docked, adding even more time to the lengthy operation.
The da Vinci robot plainly improves the quality of care received by patients and has a dramatically positive effect on post-operative care. The current model will be refined in the future and multiple companies are preparing their own models which will inject market competition and drive down the price of the machines. Currently, few NHS hospitals own a da Vinci machine but the Chancellor has pledged his support for the use of robotics in surgery. This may have been an overly ambitious promise. In view of the current economic climate and the price of these machines, it is likely that the widespread implementation of robotically assisted surgeries in the NHS is going to be a very long-term project.

By David Fisher

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