Robotic surgery

The robot that makes surgery safer is known as the da Vinci surgical system which has shown improved recovery experience and clinical outcomes for patients and surgeons respectively.

AS technology makes life more advanced and connects many individuals across the globe, one should not be surprised it has played a great role in the medical industry as well.

Robotic surgery may not ring a bell here but such technology, which promises low complications, can deliver better outcome in terms of precision.

The robot that makes surgery safer is known as the da Vinci surgical system, consisting of an ergonomically designed surgeon’s console, a patient-side cart with four interactive robotic arms, a high performance vision system and proprietary EndoWrist Instruments.

Powered by state-of-the-art robotic technology, the surgeon’s hand movements are scaled, filtered and seamlessly translated into precise movements of the EndoWrist Instruments.

The system can neither be programmed nor make decisions on its own, requiring every surgical maneuver to be performed with direct input from the surgeon.

The incorporation of robotic surgery comes with high financial outlay for the setup and maintenance costs although it has the edge over conventional laparoscopy and open surgery in terms of oncologic, clinical and functional outcomes especially for radical prostatectomy.

Training requirements also make it prohibitive for many institutions to own the da Vinci system. Nonetheless, Mount Elizabeth Hospital, Singapore, has the robot to make surgeon’s work easier for years.

Robotic surgery — as compared to the conventional laparoscopy and open surgeries — has shown improved recovery experience and clinical outcomes for both the patients and surgeons respectively.

Patients are promised shorter hospital stay, less pain and scarring, less risk of wound infections, less blood loss and fewer transfusions, faster recovery and quicker return to normal activities.

As far as surgeons are concerned, robotic surgery assures improved freedom of motion with the use of multi-articulated instruments, stable 3D and magnified visualisation, downscaling that enables surgeon to perform minute, precise movements, dampening of physiologic tremors and ergonomically “perfect position” for surgeon at a remote site.

Mount Elizabeth Hospital urologist Dr Chin Chong Min said the da Vinci robot could be used to perform surgery for prostate cancer, kidney cancer, kidney pelvis obstruction or ureter stricture, bladder cancer and bladder-vagina fistula.

Prostate cancer will be more evident in Asian men and if detected early, can be cured, he told a recent media familiarisation trip to the hospital in Singapore.

The options for organ-confined prostate cancer are radiotherapy or radical surgery. For younger men with significant-volume cancer, surgery still gives the best cure rate of up to 90 per cent survival at 10 years.

Open radical prostatectomy was the surgery of choice since 1980. However, surgery is limited by the narrow male pelvis and non water-tight anastamosis of the bladder and urethra.

“Blood loss can also be excessive with transfusion rates as high as 67 per cent. When laparoscopic surgery became popular in the 1990s, urologists keen to adopt it found the learning curve steep. Surgery was limited by ‘chopstick’ instrument movement and suturing was tedious resulting in high surgeon fatigue,” he said, adding that the first robotic prostatectomy was performed in 2000.

The da Vinci robotic system allows the surgeon to sit comfortably at a console with 10-fold magnified 3D vision. Unlike conventional laparoscopy, the robotic instruments have six-degrees of movement freedom aided by computer filtration to eliminate hand tremor and fine-scales the surgeon’s EndoWrist hand motions.

The surgeon is also in direct control of the camera and can advance and rotate it at any angle. Besides positioning and mechanical challenges, one technical disadvantage is the lack of tactile feedback.

However, with the help of a regular team, these limitations can be overcome.

“Robotic prostate surgery takes an average of four to five hours. Blood loss is minimal (less than 200ml) compared to open surgery — thanks to the superior vision and pneumo-peritoneum tamponade.

“Clinical benefits also include reduction in postoperative pain and faster recovery. Patients can be discharged as early as two days post-surgery. The challenge is in improving the oncologic, continence and potency rates.

“Not surprising, there is a trend for patients to travel to leading hospitals that offer robotic surgical technology despite its higher cost,” Dr Chin said.

He added that suturing was much easier with the robot because of EndoWrist technology that made the task dexterous and instinctive.

For standard laparoscopy, the surgeon still faces restricted instrument movement besides requiring high patient load to maintain his laparoscopic skills.

The additional comfort that robotic surgeons enjoy over their laparoscopic colleagues to achieve equivalent outcomes cannot be ignored.

“After all, robotic surgery is still laparoscopic surgery with the only difference being the assistance from the instruments.

“Robotic surgery will be recommended only when there is a high chance of recovery. Exacting is the word and precision is aided by vision. There is less damage, less blood loss and thus better outcome,” Dr Chin said.

His colleague, general surgeon Dr Ranjiv Sivanandan, said thyroid surgery could be performed without neck incision with the da Vinci system.

Robotic thyroid surgery comes with excellent cosmetic outcomes (no scars), reduced likelihoood of recurrent laryngeal nerve damage, less risk in hypoparathyroidism (decrease function in the parathyroid glands) and reduced likelihood of numbness in anterior (front) neck.

It is performed through the armpit, an incision that is subsequently well concealed. This access allows the surgeon to surgically remove the thyroid nodule, located in the lower central neck without any neck incision.

After the creation of an anatomic workspace, the robotic arms are inserted and the nodule removed completely.

“Patient is required to stay only for one night and would have a completely normal voice. This is especially suitable for ladies who have the propensity to develop unsightly surgical scars,” Dr Sivanandan said.

Thyroid operations are used for patients who have a variety of thyroid conditions, including both cancerous and benign (non-cancerous) thyroid nodules, large thyroid glands (goiters) and overactive thyroid glands.

The types of operation a surgeon may perform include biopsy or lumpectomy (removing a small part of the thyroid gland), lobectomy (removing half of the thyroid gland), subtotal thyroidectomy (removing nearly all of the thyroid gland, leaving a small amount of thyroid tissue bilaterally), near-total thyroidectomy (leaving about one gram or centimetre of thyroid tissue on one side) and total thyroidectomy (removing all identifiable thyroid tissue).

Specific indications follow each of these operations. The main risks of a thyroid operation involve possible damage to important anatomical structures near the thyroid, primarily the parathyroid glands (which regulate calcium levels) and the recurrent and external laryngeal nerves (which control the vocal cords).

Obstetrician and gynaecologist Dr Suresh Nair has lauded the da Vinci robot as an immersive telerobotic surgical system designed to accurately follow movements of the surgeon’s hands.

“It is intuitive as the surgeon moves his hand from right to left to move the robotic instruments in the same direction.

“Conventional laparoscopic surgery is counter intuitive. The surgeon has to readapt against the natural orientation such that to move the tip of the instrument from right to left, the brain has to signal the hands to do the contrary. Hence, making this type of surgery harder to master,” he said.

According to Dr Nair, operations such as removal of growths (fibroids) in the uterus that require very precise and fine stitching to close the uterine defect made in the uterus, are very securely done using the da Vinci surgical robot.

“The repair of the myomectomy defect is extremely critical in the integrity of the subsequent scar. Inadequate suture repair predisposes to uterine rupture in pregnancy, a catastrophic complication that endangers mother and child.”

For the first time in minimal access surgery, the surgeon has a 3D view of the organs through the stereoscopic viewer as the great disadvantages of conventional 2D laparoscopy is the loss of depth of field of vision.

The surgeon is able to perform very precise and accurate surgery yet seated comfortably at the surgeon console. This reduces surgeon fatigue.

“Robotic arms are tele-manipulated system for surgery to have lower rate of error. It is a slaved robot, not automated. It helps reduce fatigue; if you tire a surgeon, an error can occur,” Dr Nair pointed out.

In a nutshell, robot-enhanced surgery is a natural progression from current laparoscopic surgery to precise surgeon intuitive surgery of the future.

With time, robotic technology will improve, become more affordable and is predicted to be the standard of care for many surgeries.