The robot is the most sophisticated instrument currently available in surgery; thanks to a computer and remote handling technology the surgeon is able to reproduce the movements of the human hand in the operative field.
Robotic surgery was created with the intent to overcome the limitations of laparoscopic surgery (flat, two-dimensional vision; movement paradoxes of the instruments; unnatural positions of the surgeon; the dissociation between instrument control and vision; inability to carry out micro sutures) while maintaining the positive aspects (reduced blood loss; less postoperative pain; faster recovery of organic functions; reduction in surgical infection; reduced hospital stay and subsequent convalescence; returning to work earlier) that constitute the added value of minimally invasive surgery over traditional surgery.
The initial project, prepared by NASA and the U.S. Army in the 1980s, was taken up again in 1995 by two American companies (Intuitive Surgical and Computer Motion) which merged in 2003 giving rise to a single company: Intuitive, which is currently dominating the market for robotic surgery with their da Vinci® surgical system.
In 2000, the Food and Drug Administration approved the use of this system in general surgery thus giving the go-ahead for the vertiginous technological development and surgical indications.
Intuitive Surgical has sold nearly 2500 robotic systems, most of which in the USA. There are 54 in Italian hospitals; we are in third place in Europe after Germany and France.
More than one million robotic surgeries have been performed in the world since 2000.
THE DA VINCI © SYSTEM FOR ROBOTIC SURGERY
The system is based on three components:
- control /command console where the surgeon sits which is connected by a fiber optic cable to the robot;
- robotic cart, positioned at the side of the operating table, with four arms: one with a pair of small video cameras and three with operational instruments;
- an additional cart, holding a monitor for the surgical team and the sources of light and CO2 insufflation.
In the latest version (system da Vinci ® Si) a second console is also included, in parallel to the first, which can be used by a second surgeon in training.
The surgeon operating sits at the console watching the screen showing an enlarged, three-dimensional image from the two high-definition cameras that have been introduced into the body cavity via the laparoscopy trocar.
The surgeon’s hands operate knobs that instantly reproduce the movements made by their hands whilst eliminating tremors and expanding the range of movements.
The instruments attached to the arms of the robotic cart are different (needle drivers, forceps, clip appliers) and can be changed during the operation according to the different surgical needs.
The role of the surgeon at the operating table is fundamental, which is, in robotic surgery, represented by the operational arm
In summary, the main advantages of robotic surgery with the da Vinci ® Surgical System are:
- Three-dimensional visualization thanks to its two cameras
- Magnification of the image
- Filter of tremors
- Correspondence of movements between hand and tip of the instruments
- Seven degrees of freedom
THE CLINICAL APPLICATIONS OF ROBOTIC SURGERY
- Since the first robotic cardiac surgery, carried out in Europe in 1998 by Alain Carpentier, there is no branch of surgery that has not been affected by this surgical revolution.
The lion’s share certainly goes to urological surgery where, thanks to prostatectomy, the adoption of the robot has been extremely rapid and robotics is poised to become the gold standard for this procedure. More than 80% of prostatectomies are now performed with robotic technology in the USA. Other interesting indications in robotic urologic surgery are partial nephrectomies, stenosis of the pyeloureteral junction and total cystectomies.
In general and thoracic surgery the diffusion of robotic surgery has been slower and more difficult and it must be said that the learning curve is extremely long for more complex operations.
In gynecologic, pediatric, endocrine and ENT surgery robotic surgery is now being used where laparoscopy once was.
LIMITS OF AND POSSIBLE DEVELOPMENTS IN ROBOTIC SURGERY
A robotic platform costs more than €2 million and an annual cost of use linked to the consumption of disposable instruments and technical assistance must also be added to this initial cost. These costs are inevitably a strong limitation to its use spreading.
At present, the reduction of perioperative morbidity, shorter hospital stays, and its multidisciplinary and intensive use only partially offset the costs.
From a surgical point of view however the lack of tactile feedback is still a big limit of robotics, although, in reality, the human brain does learn to compensate with experience.
Finally, the lack of specific training centers and programs is another important limitation.