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A Game of Operation: The Growth of Robotic Surgery

by Muhammad Feroze

The dexterity and poise required to perform surgery have long been valued since the primitive procedures performed in ancient civilizations. This appreciation can be seen in the laws governing a surgeon’s performance in the Code of Hammurabi created in 1750 B.C. For example, Code 218 states, “if a physician make a large incision with the operating knife, and kill him (the patient)…his hands shall be cut off.” Fortunately, with a better understanding of human anatomy and the development of sophisticated surgical tools, surgeons now perform a plethora of procedures without doubting the validity of their techniques. Yet, as these surgical methods advance, the surgeon’s role in performing the actual procedure diminishes. This can be attributed to the growth of robotic surgery.

One misconception about robotic surgery is that an autonomous robot performs the procedure without any human intervention. Rather, a surgeon indirectly performs the surgery via remote computer console, which allows him to control the movements of mobile arms that constitute the only physical contact with the patient. Usually this console is located within the operating room and contains a camera that provides visual feedback to the surgeon. The feedback facilitates precise arm movements that emulate those of an actual surgeon. The accuracy and precision of robotic-assisted surgery has bred expectations for more efficient procedures with regards to patient stay and recovery time.

Since the advent of robotics in surgery, multiple systems have been created, of which the Da Vinci system is the most prominent. Manufactured by a Silicon Valley based company, Intuitive Surgical, the product was approved by the FDA in 2000. The system can now be found in hundreds of hospitals all over the world, with UPMC housing more than any single institution in North America. The Da Vinci system contains 4 robotic arms controlled by the surgeon with the visual aid of magnified 3-D display. Its versatility and unprecedented control has led to its use in a wide array of operations on all parts of the body.

While most used for hysterectomies and prostrate removals, the Da Vinci system has also been used in cardiac and gynecologic procedures. Another application which demonstrates its dexterity is its utility in treating head and neck cancers. This particular operation, known as transoral robotic surgery (TORS), uses the Da Vinci system to access tumors through the mouth. Traditional methods of removing throat tumors involved incisions extending from the lips to the throat. The use of a robotic arm capable of maneuvering through such anatomically restricted area negates the need for such an incision. The smaller incisions are not only cosmetically appealing but also reduce blood loss and risk of infection. Umamaheswar Duvvuri, MD, an otolaryngologist at UPMC describes the advantage of robotic surgery in treating head and neck cancers by stating, “patients are often attracted to smaller incisions and a faster recover period.”

While the expanded capabilities for the surgeon and improved efficiency of the operation are indisputable, whether or not robotic surgery leads to faster recovery times and shorter hospital stays remains a central question. With a robotic operation usually more expensive than the traditional options, is it cost effective for the patient through a shorter hospitalization? Moreover, from the small hospital’s perspective, does the initial expense of a robotic surgical system matter if it attracts patients who would normally seek care elsewhere?

Although robotic surgery has become the convention for a variety of operations, few studies have been done to assess its improved clinical outcomes. The data in favor of robotic surgery over other traditional, minimally invasive techniques varies from procedure to procedure. In a population-based study in England, national data for 4275 patients undergoing a partial nephrectomy showed that robotic surgery had fewer complications after 90 days and lower costs for intervention one year after the operation. Another comparative study showed that robotic surgery for rectal cancer did not enhance clinical results compared to the laparoscopic method. While robotic surgery generally has greater operating costs, more data must be collected regarding the favorable outcomes based on each procedure offered. Through this information, the doctor and the patient can weigh options to ensure the optimal treatment.

However, the lack of clinical studies has not limited the growth and potential of robotic surgery. Perhaps the most quintessential example of such potential is remote surgery. Coined telesurgery, it involves the surgeon operating on the patient from a distant physical location. In 2001, a landmark teleoperation known as the Lindbergh Operation was performed, in which surgeons in New York operated on a patient in Strasbourg, France. The procedure, a cholecystectomy, was performed with the use of the ZEUS robotic surgical system which is structurally similar to the Da Vinci system.

With further advancements in telesurgery, various industries have sought the potential for its applications. For example, telesurgery drew interest from NASA, as a method to treat astronauts who spend a long duration in space. They have experimented with telesurgery using equipment physically located on airplanes. These test flights are modeled to mimic different conditions such as turbulence and the lack of gravity. Through experimentation, the appropriate software is being designed for longer trips to perhaps the moon, or even Mars. While this application may take years to be fully developed and implemented, an imminent use of robotic surgery outside civilian life could be by the military to treat soldiers on the battlefield.

Known as the Trauma Pod program, this initiative is funded by an agency of the Department of Defense with the mission of operating on a compromised soldier to address urgent needs. Creating a robot that can assess and stabilize injured soldiers in a harsh environment requires teams of engineers and programmers. Thus far, a system that could perform intravenous access has yet to be created. However, once fully designed, such an innovation would be a unique application of robotic surgery with the potential to save many lives.

As unique procedures are being performed using the Da Vinci system and other robotic technologies every day, the full potential of this technology on healthcare delivery remains yet to be seen. Its conceivable applications have attracted much attention, prompting continued research and development. Still, robotic surgery has proved to be a useful tool to surgeons by providing greater precision and accuracy. It has also decreased the patient’s distress after the operation. Refinements to this innovative technology will evolve the prehistoric discipline of surgery further than ever envisioned.