1、Robotics in Surgery,Marc S. Milsten, M.D., F.A.C.S. Urologic Specialists of Oklahoma November 17, 2007,Definition of a Robot,Machine that resembles a human and does mechanical, routine tasks on command Any mechanical device that operates automatically with human-like skill “A robot is not a machine.
2、it is an information system with arms”,Robots: Better Than Humans?,Robots: Better Than Humans?,Types of Robots,Passive Retractor system Position the tool and then hold Active Robot would actively move the tool upon the surgeons command,Surgical Robots in 2007,AESOP (Automated Endoscopic System for O
3、ptimal Positioning)- Voice activated mechanical arm- Steadier than human, never tires daVinci- FDA approval in 2002- Laparoscopic instrumentation controlled by the surgeon positioned remotely at a console,Development of daVinci,Defense Advanced Research Projects Agency (DARPA) for military research
4、of remote battlefield surgery Cholecystectomy performed remotely via telesurgery from 300 miles away Intuitive Surgical created in 1999 after acquiring patent rights from military First robotic prostatectomy performed in 2001,“Operation Lindberg”: Remote Transatlantic Telesurgery,Remote Surgery,Adva
5、ntages of Laparoscopic Surgery,Shorter hospital stay Less pain Less risk of infection Less blood loss and transfusions Less scarring Faster recovery Quicker return to normal activities,Challenges of Laparoscopic Prostatectomy,Prostate located in fixed confines of pelvis Laparoscopic instruments limi
6、ted in articulated movements Approximation of bladder-urethral anastomosis difficult to suture French experience: 300 cases reported, learning curve 100 Oklahoma experience: 1 case, 19 hours, patient died,Advantages of daVinci Robot,Magnified (12x), stereoscopic 3-D vision Robotic wrist with 6 degre
7、es of freedom Movements are scaled, filtered, translated,daVinci Robotic System,Disadvantages of daVinci Robot,Expensive- $1.4 million cost for machine- $120,000 annual maintenance contract- Disposable instruments $2000/case- Hospital reimbursement same DRG Steep surgical learning curve Increased st
8、aff training/competance Increased OR set-up/turnover time,Robotic Disbelievers,“No long term data”- Margin positive rates equivalent- No difference in risk for incontinence and erectile dysfunction “Loss of tactile feedback”- Improved vision- Haptic feedback: visual resistance ENABLER: same operatio
9、n, new tool,daVinci Robotic Prostatectomy,Open Robotic OR time 3 hrs 2-4 hrs Hospital stay 3 days 24 hrs Foley catheter 14 days 7 days Blood loss 600 ml 100ml Recovery 4-6 wks 2-3 wks,Margin Positivity,Series % Positive marginsSoloway (Open) 28 %Lepor (Open) 26 %Guillonneau (Laparoscopic) 13.7 %Abbo
10、u (Laparoscopic) 20%Rassweiler (Laparoscopic) 24 %Turk (Laparoscopic) 26 %Bollens (Laparoscopic) 22 %Sulser (Laparoscopic) 18%Menon (Robotic) 26%, 17%, 6%Ahlering (Robotic) 17%Lee (Robotic) 21%,Continence Data,Surgeon 3 mo 6 mo 12 moWalsh (Open) 54 % 80% 93%Abbou (Laparoscopic) 58% 69% 78%Guillonnea
11、u (Laparoscopic) N/A N/A 85 %Rassweiler (Laparoscopic) 54% 74% 97%Menon (Robotic) N/A 96% N/AAhlering (Robotic) 76% 91% 94%Lee (Robotic) 60% 82% N/A,Potency Data,Author Capable of IntercourseWalsh (age 60 to 67) (Open) 75%Catalona (60s/70s) (Open) 60% / 47%Guillonneau (Laparoscopic) 66% overallAbbou
12、 (Laparoscopic) 54%Turk (Laparoscopic) 59%Menon (Robotic) 64%Ahlering (Robotic) 65%Lee (Robotic) Too early,Tulsa daVinci Experience,Machine located at St. John 130 prostatectomies performed to date Average operative time 2-3 hours 95% patients discharged in 24 hours No conversions to open surgery Co
13、mplications: 2 post-op bleed, 1 port site hernia, 1 anastomotic stricture,daVinci Clinical Applications,Urology: radical prostatectomy, dismembered pyeloplasty, radical cystectomy, cyst decortication Cardiac: mitral and aortic valve replacement, aorto-iliac bypass, off-pump synchronized bypass GYN:
14、hysterectomy, prolapse repair, tubal reversals, fistula repair, myomectomy General: gastric bypass, Nissen,daVinci Clinical Limitations,No advantage over standard laparscopic approach for cholecystectomy, spleenectomy, colectomy Increased operative time observed Precise dissection not necessary Open
15、 space: limitations with broad sweeping motions,daVinci vs. Laparoscopy,Laparoscopic surgical fellow at Stanford First 50 Roux-en-Y procedures randomized laparoscopic or robotic with DaVinci Both surgery with hand-sewn anastomosis OR time: 149 min (lap) vs 131 min (robot) No difference for complicat
16、ions, LOS, EBL Conclusion: Robot is an ENABLER,Off-pump CABG,30 patients, 2.6 grafts/patient Majority: IMA to LAD 15/30 discharged 24 hours Complications:- 2 return to OR for bleeding- 1 converted to open- 2 readmits: pleural effusion, wound infection No mortality,Advanced Endoscopy,Natural Orifice
17、Surgery,Courtesy of N Reddy, Hyperbad India 20005,Courtesy of N Reddy, Hyperbad India 20005,Peroral Transgastric Endoscopic Surgery Natural Orifice Transluminal Endoscopic Surgery (NOTES),Trans-gastric Appendectomy,Climbing the Learning Curve,Standard surgery: “see one, do one, teach one” Robotic su
18、rgery: “see one, do one, kill one” Requires entirely new skill set beyond traditional surgical and laparoscopic training Training opportunities limited Animal labs helpful Cases require outside proctor to determine competency Credentialing challenges?,Surgical Simulation,Surgical Simulation Red Drag
19、on/Blue Dragon,Hand Motion Assessment,Robotic Rounding,Robotic Scrub Nurse “Penelope”,Robotic Scrub Nurse,Operating Room of the Future,Moral Dilemma,Technology is neutral - it is neither good or evilIt is up to us to breathe the moral and ethical life into these technologiesAnd then apply them with
20、empathy and compassion for each and every patient,Conclusions,The rate of discovery of new technology is outpacing the ability of business, society, and healthcare to integrate and apply Robotic surgery is but one example of such technology that MAY reduce operative morbidity, hospital stay, and recovery, while POTENTIALLY improving clinical outcomes, but at what point do the BENEFITS justify the increased EXPENSE?,
