Dr. R Dayananda Babu,
Prof of Surgery and HOD, Sree Gokulam Medical College
7th September 2001 was a landmark memorable day in the history of surgery. Michale Gagner performed the first transatlantic surgery – a robotic system was utilised to perform a cholecystectomy on a patient in Strasbourg while the surgeon was comfortably positioned in New York. However Rome was not made in a days work.
A lot of research and hardwork behind the scenes had been made for years together. Transatlantic cables of specific dimensions had to be laid and various problems encountered, and of course, shot down in attempting to transmit the signals. It had been deduced earlier that a transmission time delay of about 300 milliseconds was compatible with the safe performance of surgical procedures.ATM fibres were utilised to bring down the tie delay to 155 milliseconds. Lastly a series of 6 pigs had been operated on before the first operation on a human being was attempted.
And erstwhile fantasy is today’s reality. The fact that the surgeon is not even near to the patient but is seated comfortably in a remote location is, at first glance, the stuff science fiction is made of. I could not dream of it while I was amedical student. The surgical robot is the culmination of the combined work of engineers, computer scientists, entrepreneurs and surgeons
The history of surgery is through various wars. The concept of telerobotic surgery was first developed with grants from the United States department of defence. The United States army wanted to develop a machine by which combat surgeons could operate from a remote safe location on wounded soldiers on the battle field where 90% of all combat deaths occur before they reach the military hospital.
One of the earliest recorded use of medical robot was in 1985 when Puma 560, used by Kwoh et al performed neurosurgical biopsies with greater precision. Three years down the lane the same instrument was utilised by Davies to perform a transurethral resection. Advances along this direction gave birth to PROBOT—an instrument created specifically for transurethral resection. Orthopaedic surgeons were not to be left behind. ROBODOC was introduced by integrated surgical supplies of Sarcamento. This instrument, one of the first FDA approved systems was designed to move the femur during hip replacement surgeries. Robot was first introduced in laparoscopic cholecystectomy in 1987. A voice activated endoscopic positioning system called AESOP (Automated Endoscopic System for Optimal Positioning) was brought forward by computer motion.inc in 1993. This became the first approved for surgery. The same organisation went on to develop another system called HERMES which accepts centralised voice commands and recognition system. The ZEUS system was introduced by computer motion in 1998. Almost at the same time, integrated surgical systems (which later became intuitive surgery inc) created the DAVINCI system – an instrument that utilised the endowrist and a true 3 dimensional view. After being approved by for laparoscopic surgery in 2000, this system was approved for mitral valve surgeries in 2002. In the meanwhile computer motion introduced the Socrates robotic telecommunication system in 2001. Subsequently intuitive surgical merged with the computer motion group in September 2001 – the day of the Lindberg Surgery
All the major robotic systems introduced have a few features in common – To provide maximum control and dexterity to the surgeon’s fingers at the console once it is connected to the jaws of the instrument in a virtual manner. Tip control with provision of seven degree of freedom ensures the surgeon’s orientation is never lost and the movements are true to the surgeon’s intentions. An elaborate safety system was devised to check the servomotors and verify the position of the tool tips every 750 microseconds to eliminate the possibility of erroneous movements.
The robotic system perse consists of the surgeon side, patient side and 3D imaging system. The surgeon side consists of a console that takes the surgeons input. The surgeon sits in a comfortable chair in front of the video monitor. The computer interphase eliminates the surgeon’s intention tremor and can be set to down scale the surgeons hand movements over a range of 2.1 to 10.1. The surgeon robot interface is one of the most sensitive sections of the system. The surgeon’s hands are inserted into freely moving grip handles called masters – they convert 3D motions of the surgeon’s hands into electrical signals. The computer translates these electrical signals into computer commands that drive the robotic instruments into perform identical 3D movements. An infrared beam inactivates the robotic tower whenever the surgeon removes his eye from the special binoculars. The surgeons arms are supported by the padded arm rests.
The console (termed the master) displays the video image of the patient and is designed to electrically accept and transfer the motions of the surgeon’s hand back to the telerobot (the slave) at the surgical site. Thus the surgeon is using the master / slave system to carry out the surgical task. An array of control buttons in the arm rest panel allows the surgeon to perform the following functions – set the viewing height, choose between 2D and 3D imaging of the virtual operating field, choose between 0 and 30 degree telescopes and utilise motion scaling e.g. 5:1 or 3:1. The console also bears section of the foot controls which serve the following functions – electro cautery activation, ultrasonic instrument activation, focal point of video cameras, and clutch for the masters. Stepping on this allows the surgeon to disengage the master form the control of the robotic instruments to reposition them to more comfortable arrangement and control of the robotic arms.
The equipment(the davinci system) and patient side. The assistant and the nurse will be standing by the side of the patient. The patient side cart consists of 3 (or 4) interactive robotic arms – 2 arms that translate the surgeons movements into actual instrument manipulator and an addition voice controlled robotic arm to control the endoscopic camera, a variety of instruments can be connected to the robotic arms – graspers,scissors , hooks etc. can be activated by simply manipulating the handles at the surgeons console. The instruments jointed wrist design exceed the natural range of motion of the humanhand .Motion scaling and tremor reduction further refine the surgeons hand movements.
The davinci system always requires a human operator and incorporates multiple redundant safety features designed to minimise opportunities of human error when compared with traditional approaches.
3D imaging system – Two separateright and left video cameras that visualise the operating field, a computer that merges and accelerates images and a video monitor with an active matrix covering its surface.
The surgeon wears glasses having a clockwise polarizing filter on the right lens and an anticlockwise filter in the left. The eyes see the imagesfrom ipsilateral cameras allowing a 3D image projection from the video monitor.
The dexterity and precision offered by robotic surgery comes at a price. There is a steep learning curve for both surgeons and staff and the disposable instruments are quiet expensive. The procedures are associated with an increased OT set up/turn over time. Conversion to conventional laparoscopic surgery must be anticipated to happen in any or all of the procedures initially. Naturally in a developing country like ours the use is ideally confined to procedures that demand a very high level of dexterity and precision e.g. pelvic nerve sparing surgeries and beating heart surgeries.
Other uses of robotic surgery include c cardiology – for CABG, valve repair,closure of ASD, urology – radical prostatectomy, renal surgery and adrenalectomy, bariatric surgery, Spine and orthopaedic surgery including hip replacement, ENT and fascio maxillary surgery and other GI surgeries – pancreaticodeudenectomy, Hellers myotomy, hiatal hernia surgery etc.
Robotics in surgery is a success of engineers, computer scientists, surgeons, and entrepreneurs. The utility of robotics in surgery will extend far beyond the current capabilities. The number of surgical arms will increase and their size will shrink. There are moral and ethical dilemmas. If there is disagreement between judgement of the surgeon and the alternatives suggested by the robot, should the surgeons choice prevail? Will there be erosion of doctor patient relationship? The science will not wait for no one!We must be in a position to control the technology.