Merits, Demerits and Future of Robotic Surgery

Developments in Robotic Surgery and Types of Machines
Robot-Assisted Spine Surgery and Innovations
Force and Tactile Sensing for Robotic MIS
Merits, Demerits and Future of Robotics
Case Study

Advantages of Robot Assisted Surgery

The advantages of these systems are many because they overcome many of the obstacles of laparoscopic surgery. They increase dexterity, restore proper hand-eye coordination and an ergonomic position, and improve visualization. In addition, these systems make surgeries that were technically difficult or unfeasible previously, now possible. These robotic systems enhance dexterity in several ways - instruments with increased degrees of freedom greatly enhance the surgeon’s ability to manipulate instruments and thus the tissues. These systems are designed so that the surgeons’ tremor can be compensated on the end-effector motion through appropriate hardware and software filters. In addition, these systems can scale movements so that large movements of the control grips can be transformed into micro-motions inside the patient.

Another important advantage is the restoration of proper hand-eye coordination and an ergonomic position. These robotic systems eliminate the fulcrum effect, making instrument manipulation more intuitive. With the surgeon sitting at a remote, ergonomically designed workstation, current systems also eliminate the need to twist and turn in awkward positions to move the instruments and visualize the monitor.

By most accounts the enhanced vision afforded by these systems is remarkable. The three-dimensional view with depth perception is a marked improvement over the conventional laparoscopic camera views. Also to advantage is the surgeon’s ability to directly control a stable visual field with increased magnification, and maneuverability. All of this creates images with increased resolution that, combined with the increased degrees of freedom and enhanced dexterity, greatly enhances the surgeon’s ability to identify and dissect anatomic structures as well as to construct micro-anastomoses.

Disadvantages of Robot Assisted Surgery

First of all, robotic surgery is a new technology and its uses and efficacy have not yet been well established. To date, mostly studies of feasibility have been conducted and almost no long-term follow up studies have been done. Many procedures will also have to be redesigned to optimize the use of robotic arms and increase efficiency. However, time will most likely remedy these disadvantages.

Another disadvantage of these systems is their cost. With a price tag of a million dollars, their cost is nearly prohibitive. Whether the price of these systems will fall or rise is a matter of conjecture. Some believe that, with improvements in technology and as more experience is gained with robotic systems, the price will fall. Others believe that improvements in technology such as haptics, increased processor speeds, and more complex and capable software will increase the cost of these systems. Also at issue is the problem of upgrading systems; how much will hospitals and healthcare organizations have to spend on upgrades and how often? In any case, many believe that to justify the purchase of these systems they must gain widespread multidisciplinary use.

Another disadvantage is the size of these systems. Both systems have relatively large footprints and relatively cumbersome robotic arms. This is an important disadvantage in today’s already crowded operating rooms. It may be difficult for both the surgical team and the robot to fit into the operating room. Some suggest that miniaturizing the robotic arms and instruments will address the problems associated with their current size. Others believe that larger operating suites with multiple booms and wall mountings will be needed to accommodate the extra space requirements of robotic surgical systems. The cost of making room for these robots and the cost of the robots themselves make them an especially expensive technology.

One of the potential disadvantages identified is a lack of compatible instruments and equipment. Lack of certain instruments increases reliance on tableside assistants to perform part of the surgery. This, however, is a transient disadvantage because new technologies have and will develop to address these shortcomings.

Other Complications: For any major surgery, there is a risk for a wide range of potential complications. Robotic surgery does not eliminate these risks. Additionally, certain other risks may be posed. Surgery times can be increased, due to the need to adjust the robot properly to the patient, leading to potentially increased risk of infection. Some systems require extra means of fastening the robot to the patient, which could lead to increased blood loss or infection. Robotic malfunction, while rare, can occur, and may require a system reboot, or the abandoning of the robotic portion of the surgery in favor of traditional techniques. Finally, local injuries may occur due to exposure to the robot, which might otherwise not occur using traditional tools and techniques.

Most of the disadvantages identified will be remedied with time and improvements in technology. Only time will tell if the use of these systems justifies their cost. If the cost of these systems remains high and they do not reduce the cost of routine procedures, it is unlikely that there will be a robot in every OR and thus unlikely that they will be used for routine surgeries.

The Future of Robotic Surgery

Robotic surgery is in its infancy. Many obstacles and disadvantages will be resolved in time and no doubt many other questions will arise. Many questions have yet to be asked; questions such as malpractice liability, credentialing, training requirements, and interstate licensing for tele-surgeons.

Many of current advantages in robotic assisted surgery ensure its continued development and expansion. For example, the sophistication of the controls and the multiple degrees of freedom afforded by the Zeus and da Vinci systems allow increased mobility and no tremor without comprising the visual field to make micro anastomosis possible. Many have made the observation that robotic systems are information systems and as such they have the ability to interface and integrate many of the technologies being developed for and currently used in the operating room. One exciting possibility is expanding the use of pre-operative (CT or MR) and intra-operative video image fusion to better guide the surgeon in dissection and identifying pathology. This data may also be used to rehearse complex procedures before they are undertaken. The nature of robotic systems also makes the possibility of long distance intraoperative consultation or guidance possible and it may provide new opportunities for teaching and assessment of new surgeons through mentoring and simulation. Computer Motion, the makers of the Zeus robotic surgical system, is already marketing a device called SOCRATES that allows surgeons at remote sites to connect to an operating room and share video and audio, to use a ‘telestrator’ to highlight anatomy, and to control the AESOP endoscopic camera.

Technically much remains to be done before robotic surgery’s full potential can be realized. While these systems have greatly improved dexterity they have yet to develop the full potential in instrumentation or to incorporate the full range of sensory input. One of the “holy grails” of robotic surgery is to endow the systems with true force reflection and haptic feedback; however the presence of the numerous mechanical joints inherently imparts additional friction to the entire kinematic chain. It is therefore difficult to distinguish friction that originates from the robotic system and forces from living tissue. This limitation can be overcome with the development of newer computer algorithms and microsensors that can be positioned at the tips of the instruments. The control handles of such a system as the da Vinci both sense a surgeon’s hand movements and are electronically powered and can relay force information back to the surgeon. Tissue tension can be delivered, as in conventional surgery, as can any range of biological data. For instance, the pulsations of a diminutive artery can be enhanced and magnified such that it is palpable to the surgeon at the console. Other variables that are not in the average realm of human perception (e.g. oxygen tension, temperature, and density) may also be conveyed, as demonstrated in the U.S. National Aeronautics and Space Administration Smart Probe project.

The fact that robotic systems can track a surgeon’s hand movements brings with it the ability to record that wealth of data. Thus, every nuance of a master surgeon’s performance, as well as the visual information from the operation, may be preserved. All that information may then be replayed in its entirety for those in training. Rather than stumble through an operation step by step, a novice may be able first to mimic, then to perform, an operation as it was meant to be. This “player piano” model may be invaluable in surgical education and could change the manner in which future generations learn to operate.

Computer systems are also much more facile than the human mind at processing complex coordinate frames of reference. For example, the operative instruments can be programmed to always align with the axis of view of the endoscope. Thus, wherever the endoscope is angled, it would appear to the surgeon that he or she is positioned at the end of the endoscope. For instance, an angled endoscope inserted into the mouth and directed back toward the nasopharynx could establish a vantage point for the operative instruments such that one could seem to operate through the back of the patient’s head.

Although the current robotic systems represent great strides in technology, the possibilities for innovation are virtually endless. Much like the robots in popular culture, the future of robotics in surgery is limited only by imagination. Many future “advancements” are already being researched. Some labs, are currently working on systems to relay touch sensation from robotic instruments back to the surgeon. Other labs are working on improving current methods and developing new devices for suture-less anastomoses. When most people think about robotics they think about automation. The possibility of automating some tasks is both exciting and controversial. The possibilities for improvement and advancement are only limited by imagination and cost.