Mankind has always strived to improve its quality of life and make it more comfortable starting from the Stone Age. This has led to many ground-breaking innovations and discoveries. The effect is seen in all sectors, infrastructure, Information and technology, entertainment etc. One of the major innovations have been the introduction of robots.
‘Robots’ is derived from the Czech word ‘Robota’ meaning forced labour. The robots were initially meaningless machines designed to do repetitive tasks but over a period of time they have evolved into more sophisticated entities with a wide variety of applications. The Robots made their presence felt in the field of medicine only recently. The field of surgery has been more than receptive towards accepting this technology in treating patients in a minimally invasive way. But let us know how did this revolution began?
Laparoscopic surgery is the mother of Robotic surgery
Before the arrival of the Robots on the surgical scene laparoscopy ruled the roost as far as minimally invasive surgery is concerned. Some of the inherent disadvantages of laparoscopic surgeries are loss of haptic feedback (force and tactile), natural hand-eye coordination, and dexterity. The movements of laparoscopic instruments while watching a 2-D video is counter-intuitive (i.e. one must move the instrument in the opposite direction from the desired target on the monitor to interact with it). This is also called as ‘fulcrum effect’ which compromises the hand-eye coordination. Other two important drawbacks are that most of the instruments have 4 degrees of motion whereas the human hand has 7 degrees of motion which is emulated by the robot effectively. Secondly, physiologic tremors in the surgeon which are readily transmitted through the length of rigid instruments, making more delicate dissections and anastomoses difficult, if not impossible are non-existent while operating using the robot. “Necessity is the mother of invention” and hence the idea to develop robots sprung up from the need of overcoming the limitations of current laparoscopic technologies and also to enhance the benefits of minimally invasive surgery.
The arrival of the surgical robots
The history of robotics in surgery begins with the Puma 560, a robot used to perform biopsies in neurosurgery with greater precision. Then came the PROBOT which was used to treat prostate ailments endoscopically. The National Air and Space Administration (NASA) was involved in developing telepresence surgeries. By collaborating with the US army and the Stanford Research Institute (SRI), it developed the MASH (Mobile Advanced Surgical Hospital) which would bring the surgeon to the wounded soldier via telepresence. Lured by the possible commercial success of robots many companies went commercial and ventured into civilian surgical community. Many prototypes were developed including the one which I work on i.e. the Da Vinci surgical system which is a comprehensive master-slave surgical robotic system developed by Intuitive Surgical Inc., Mountain View, CA. In the Da Vinci system, there are essentially 3 components: (1) a vision cart that holds a dual light source and dual 3D cameras, (2) a master console where the operating surgeon sits, and (3) a moveable cart where 2 instrument arms and the camera arm are mounted. The Food and Drug Administration (FDA) cleared the da Vinci Surgical System in 2000 for adult and pediatric use in urologic surgical procedures and other procedures.
How does the robot help the surgeon?
The term ‘Robotic Surgery’ may give a false impression that the surgery is performed by the Da Vinci robot autonomously. It is not the Robot who performs the surgery but it is the surgeon who controls the robotic movements and performs the surgery. This is a very common dilemma in the mind of a layman. I would hence prefer to call it as ‘Robot-assisted surgery’, ‘Robotic-assisted laparoscopic surgery’ or ‘Laparoscopic surgery with robotic assistance’. The surgeon sits at a computer station which is called the “console” and from there ‘choreographs’ the movements of the robot. Small surgical instruments are attached to the robot’s arms with the help of which he/she can make small cuts in the skin to insert the instruments into the body. A metal tube with two 3D cameras attached to it like an endoscope allows the surgeon to have a magnified (10x) 3D images of that part of the body where the surgery needs to be performed. The movements of the robot matches the hand movements of the surgeon sitting at the console with applied motion scaling. The degrees of freedom of the instruments’ jointed-wrist design exceeds the natural range of motion of the human hand. The default motion scaling and tremor reduction inbuilt in the system further refine the surgeon’s hand movements.
What is the benefit?
Robotic surgery or Robotic-assisted surgery is a revolution, especially in technically difficult and suture-intense surgeries. For surgeons it helps in performing complex surgeries more ergonomically resulting in lesser physical strain leading to lesser fatigue and better outcomes. Both open and laparoscopic surgical procedures entails considerable physical strain and have been definitely associated with some surgeon morbidity due to repetitive use injury. Since the robotic surgeon sits comfortably in an ergonomically-designed console, the conduct of robotic procedures is generally more ergonomic for the operating surgeon.
Such ergonomic differences will be more evident for lengthier procedures. In robotic surgery the surgical cuts are smaller than with traditional open surgery. The benefits include faster recovery, less pain and bleeding, less risk of infection, shorter hospital stay & smaller scars.
I believe that surgical robots are now no longer in infancy. Applications of robotic surgery are expanding rapidly into many different surgical disciplines. There is no doubt that robotic surgery has proven itself superior in areas inaccessible to conventional laparoscopic surgeries. It has the potential to expand surgical treatment beyond the limits of human perception and imagination. Even though the cost of procuring these are huge, many healthcare institutes are investing in it to project themselves as institutes offering “cutting edge” technologies. I accept that the debate between the benefit of its usage and the costs involved to implement it shall continue even further till some solid evidence places the truth before us about the ‘real’ minimal invasiveness of this technology. A lot remains to be seen and much remains to be worked out.
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