Although this term can give the impression that the robot is performing the surgery, the robot cannot run on its own. A robotic surgical system is designed to seamlessly replicate the movement of the surgeon's hands with the tips of micro-instruments. It cannot make decisions, or perform any type of movement or manoeuvre without the surgeon's direct input. Most of these robots are controlled by surgeons at the location of the surgery.
Robots are currently used not just for prostate surgery, but for hysterectomies, the removal of fibroids, joint replacements, open-heart surgery and kidney surgeries. They can be used along with MRIs to provide organ biopsies. It is also sometimes used in certain traditional open surgical procedures.
Types of Robotic Surgery
Three major advances aided by surgical robots have been remote surgery, minimally invasive surgery and unmanned surgery.
The goal of using robots in medicine is to provide improved diagnostic abilities, a less invasive and more comfortable experience for the patient, and the ability to do smaller and more precise interventions.
Remote surgery (also known as tele-surgery) is when a surgeon performs surgery on a patient even though they are not physically in the same location. Remote surgery combines elements of robotics, communication technology and management information systems—essentially advanced telecommuting for surgeons, where the physical distance between the surgeon and the patient does not affect the success of the procedure.
Since the physician can see images of the patient and control the robot through a computer, he/she does not need to be in the same room, or even at the same location, as the patient: a specialist can operate on a patient who is very far away without either of them having to travel. This enables specialist surgeons to make their expertise available to patients worldwide, even in remote or difficult locations, without the need for patients to travel beyond their local hospital.
This procedure can also significantly reduce patient trauma that might otherwise arise from less precisely guided operations. It provides a better work environment for the physician by reducing strain and fatigue. Surgeries that last for hours can cause even the best surgeons to experience hand fatigue and tremors, whereas robots are much steadier and smoother.
The first transatlantic remote surgical procedure took place in 2001, using the ZEUS robotic surgical system. Dr Michel Gagner, a surgeon in New York, performed a gall bladder operation on a patient 4,000 miles (6,437 km) away in Strasbourg, France.
Minimally Invasive Surgery
Robotic surgery is commonly associated with minimally invasive surgery—procedures performed through tiny incisions, also known as keyhole surgery.
The surgeon's role in unmanned surgeries is to prepare and plan the procedure, program the robot and then oversee the operation. He or she will not become directly involved in the operation, unless there is a problem. Such procedures are only possible once the area where the operation is to take place has been fully mapped using tools such as computerised tomography (CT) scans, magnetic resonance imaging (MRI) scans, ultrasonography, fluoroscopy or X-ray photography.
The first unmanned robotic surgery took place in Italy in 2006 on a 47-year-old male to correct heart arrhythmia (irregular heart rate).
Robotic Surgical Systems
A robot surgical system generally consists of one or more arms (controlled by the surgeon), a master controller (console), and a sensory system giving feedback to the user.
In 1985 a robot, the PUMA 560, was used to place a needle for a brain biopsy using CT guidance. In 1988, the PROBOT, developed at Imperial College London, was used to perform prostatic surgery.
The ROBODOC from Integrated Surgical Systems was introduced in 1992 to mill out precise fittings in the femur for hip replacement. Further development of robotic systems was carried out by Intuitive Surgical with the introduction of the da Vinci Surgical System and Computer Motion with the AESOP and the ZEUS robotic surgical system. (Intuitive Surgical bought Computer Motion in 2003; ZEUS is no longer being actively marketed.)
Robotic surgery with the da Vinci Surgical System was approved in the US in 2000. The system comprises three components: a surgeon's console, a patient-side robotic cart with 4 arms manipulated by the surgeon, and a high-definition 3D vision system. This technique has been rapidly adopted by hospitals in the United States and Europe for use in the treatment of a wide range of conditions, including surgery for prostate cancer, hysterectomy (removal of a woman’s womb) and to repair the mitral valve (a valve in the heart).
The Pros and Cons of Robotic Surgery
The advantages of robotic surgery for patients are manifold. Using robots helps reduce tremor and fatigue in surgeons, especially in complicated surgeries that can last many hours—this consistent performance improves the overall quality of the surgical procedure. Pre-programmed movements enable greater precision and accuracy than a human surgeon is capable of. Faster, more precise surgical procedures also reduce the time taken for routine operations, thereby decreasing potential blood loss that would otherwise be associated with certain procedures. Robotic surgical systems are resistant to infection, and the ability to make smaller incisions means less trauma for patients, less pain, fewer complications and a quicker healing time—less time spent in intensive care or recuperating in hospital wards.
However, medical robotics is still a relatively new idea, and comparatively expensive, which can make it prohibitive for many hospitals and healthcare centres. It is best to exercise caution and always consult a physician and/or a specialist when choosing a procedure as part of a treatment plan.
Like any conventional open surgical procedure, robotic surgery carries with it some amount of risk, such as infection or complications, and while robotic surgery is potentially faster than conventional surgery, this is not always the case in practice: there can be problems for surgeons in communicating with their assistants, especially in remote surgical procedures; technical problems sometimes arise, including malfunction and collision of instruments; and there are also still issues with latency—the time lapse between the moments when the physician moves the controls and when the robot responds.
Robotic surgical systems are also unable to completely eliminate the possibility of human error: the surgeon may incorrectly program the robot prior to surgery. If this happens, the robot, lacking human judgement, is unable to change its course during the surgery, and will do only what it has been programmed to do, while a human surgeon is able to react to unforeseen circumstances and will make any necessary adjustments to the procedure.
High cost of equipment for a robotic surgical system means that routine operations using robots may be less cost-effective than standard procedures, and it is difficult for surgeons specialising in robotic surgery to maintain their skills because there are so few cases involving robotic surgery.
Head and Neck Robotic Surgery
Tumours in the throat, base of the tongue, and tonsils can be a technical challenge to reach and have traditionally been removed through surgeries requiring a large neck incision and cutting of the bottom jaw. These types of surgeries often require long hospital stays, extensive rehabilitation and may result in difficulty in swallowing and speaking.
Advances in surgical equipment have made it possible to reach these tumours through the mouth by using robotic technology and minimally invasive techniques, allowing for a guided endoscope to provide a high resolution, 3D image of the back of the mouth and throat—a difficult area to reach with conventional tools. This robotic procedure enables surgeons to work from within a patient’s mouth, avoiding external incisions in the neck and jaw that can leave an individual with permanent scarring and difficulties in eating, speaking and swallowing.
GetDoc interviewed an ENT specialist in Singapore about Robotic Surgery: Dr Ralph Stanley, of Stanley ENT and Sinus Centre. We asked him to share some of his views on Robotic Surgery in general, and specifically in the ENT/Head and Neck area.
Dr Stanley graduated from the University of Singapore with an MBBS degree in 1978. In 1982 he was awarded Fellowship of the Royal College of Surgeons of Edinburgh (FRCS) in Ear, Nose & Throat Surgery. He was also Head & Senior Consultant, Department of Ear Nose Throat Surgery, at Singapore General Hospital from 1992 to 1995, Visiting Professor at Stanford University’s Department of Otolaryngology / Head & Neck Surgery in 1993, and Course Director in Endoscopic Sinus Surgery in Vietnam.
GetDoc: Why did you choose to specialise in ENT?
Dr Stanley: When I did my basic surgical training, I knew I wanted to do surgery. I was not the non-surgical type of person (ie. a physician), and I had the option to choose almost any surgical specialty when I was ready for specialization in the early 1980’s. What was always of immediate concern, was a sense of work-life balance, in a surgical specialty. ENT or eye surgery were the two specialities which I considered. It did give me a projected decent work-life balance in the years to come but I was not keen to do neuro-surgery or open heart surgery or even general surgery, which would entail operating under emergency conditions after office hours, in the middle of the night and over weekends. I chose ENT at that point in time because at that time it was a rather underdeveloped speciality as compared to eye surgery which was more established. I thought the growth potential in ENT would have been much better and hence I embarked on Ear, Nose and Throat training and to date I have not regretted this decision.
GetDoc: What are your views on Robotic Surgery (in general and also specifically in the field of ENT/Head & Neck)?
Dr Stanley: New advances in surgery would have to be tried, tested and proven. If you go back twenty or thirty years ago, the first minimally invasive surgery was laparoscopic, cholicystectomy. I was training in ENT during t that period, where a handful of enthusiastic young surgeons embarked on the laparoscopic minimally invasive technique. Yes, there were scorn and doubt amongst the more established general surgeons. Initially the learning curve for this technique was steep and only a few surgeons had the stamina to persist and refine the techniques then. With better instrumentation, persistence and enthusiasm of the younger surgeons, laparoscopic cholecystectomy is the gold standard for surgery of an inflamed gall bladder to-date. After the initial learning curve, it was extended to most aspects of intra-abdominal surgery and even intra-thoracic surgery.
Robotic surgery is also in the stage of initial development. The difference of it right now is that: 1. the cost is prohibitive, and 2. it is used for certain specific conditions which are not as common as cholecystectomy, hence the number of patients can be exposed to this surgical procedure is limited. As such the learning curve to obtain access to the robotic surgical system is prohibited by cost and number of patients that are available to be operated on. Due to the fewer patients we have in Singapore, the learning curve would be steeper and last longer before it enters into the main stream of surgery as the gold standard. To-date, robotic surgery of the prostate is a serious option to be considered for open prostatectomy with robotic surgery, provided patients can afford it.
With regards to ENT Head & Neck Surgery, the malignant tumours here are rather large and advanced at the time of presentation and hence the conventional surgery would have to be used most of the time. Unless we get early Head & Neck cancers in the larynx and pharynx, we would be limited in the use of robotic surgery in the surgical resection of the malignant Head and Neck tumours. The other area would be of significant help would be in the posterior base of tongue section for obstructive sleep apnea syndrome. There are many patients who require this procedure and I think robotic surgery in the ENT Head & Neck area would have its best chance in the area of Base-of-Tongue Resection for Obstructive Sleep Apnea Syndrome.
GetDoc: There is not much information on Robotic Surgery available to the average Singaporean—in your opinion is this technology something that should be encouraged to be brought in to Singapore and further developed in the local healthcare industry?
Dr Stanley: Yes! Robotic surgery is already in Singapore. We need to bring the costs down and have more surgical experience.
We need to train and limit its use to specific number of surgeons who have the aptitude and skill to perform the surgery. Because of the volume of patients we have here in Singapore are limited, not everybody has a chance at Robotic Surgery randomly. A pre-selected few in a specialized centre in Singapore would be the only hope for Singapore to develop robotic surgery into a world-class surgical centre. Robotic surgery is a definite benefit for prostatectomy for cancer of the prostate and should be further encouraged in designated centres.
1.All About Robotic Surgery
2. Robotic Surgery Health Guide
3. Robotic-Assisted Surgery
4. Tests and Procedures: Robotic Surgery
5. Head and Neck Cancer Robotic Surgery
6. Head and Neck Robotic Surgery
To know more about Dr Ralph Stanley, kindly check here
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Qian's interest in healthcare industry came about after her father was diagnosed with bladder cancer. This experience has led her to become a strong believer in empowering individuals to take charge of their own health. View all articles by Qian.