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da Vinci - The Renaissance of Surgery

Updated: Jan 3, 2020


In medicine, when we talk about any new technology, medication, intervention, or treatment modality, we have to be skeptical of its true value and safety. Even after a new tool has received FDA approval, physicians have to ensure that on a large scale, patients will not be harmed. In order to understand robotic surgery, we have to first look back at the history of this new and rapidly changing technology.


Let's Go Back in Time

Evidence of surgery or intervention on the human body goes as far back as 6500 B.C.E. when drilling a hole in the skull or trepanation, was believed to provide relief from various maladies. It was not until much later around 1500 C.E. that barber-surgeons started turning surgery into a profession. However, the tools to perform any meaningful surgery were not available and surgery was more harmful than therapeutic. The introduction of anesthesia in 1846 changed the field forever by allowing the barber-surgeon ample time to cut and sew without visible agony of the patient. Fast forward to 1867 when Joseph Lister introduced the Antiseptic Principle to the field of surgical care. Introduction of antibiotics was the next major breakthrough in 1928 and the field of surgery rapidly developed thereafter.


History of Laparoscopic Surgery



Laparoscopic surgery is thought to have started in 1805 when Philip Bozzini from Mainz, Germany, developed the first cystoscope called the "Lichtleiter" or light-conductor. The light source was a candle and it was mainly used for urologic applications such as looking inside the urethra or bladder. It wasn't until 1901 that Von Ott inspected the abdominal cavity of a pregnant woman with a speculum and light source. This was, of course, not laparoscopy as we know it today. Therefore, many credit Georg Kelling, who around the same time performed laparoscopy with filtered air to achieve pneumoperitoneum and a cystoscope in dogs and later humans. Jacobeus later published on a series of "laparothorakoskopie" and modifications of this technique started surfacing.


At this point laparoscopy was mainly for diagnostic purposes. This changed in the 1980s when Kurt Semm performed the first laparoscopic appendectomy. His technique was considered rudimentary and heavily criticized. Why would anyone want to distance themselves from a patient by using long and difficult to control sticks? But before long, many surgeons from around the world started experimenting with this new idea and eventually laparoscopic surgery became the standard in minimally invasive surgery.


Advent of Robotic Surgery

The term "Robot" is though to stem from the Czech/Slavic language and is credited to Karel Capek, who introduced the term in his play Rossom's Universal Robots. It wasn't until the 1980s when one of the first robots, the PUMA 560, was used to assist in neurosurgical biopsies. The PROBOT was later developed and designed to perform Transurethral Resections of Prostate. The first FDA approved robot was the ROBODOC, created by Integrated Surgical in California that assisted with hip replacement surgeries.



All of these robots were directly controlled from the bedside until telepresence surgery was introduced through a joint effort by NASA and Stanford Research Institute under contract by the US Army. The hope was to "bring the surgeon to the wounded soldier" on the battle field.


Computer Motion of Santa Barbara and Integrated Surgical Systems (now known as Intuitive) developed the first commercial robots in the late 90s. In 2000 the da Vinci surgical system received approval for general laparoscopic surgery. In 2003 Intuitive bought Computer Motion and became a monopoly in the robotic surgical industry.


The da Vinci system has come a long way since its inception in 1999 and is now in the fourth generation and developing rapidly. In comparison, in 1999 the Palm was the most popular PDA. In 2006 when the second generation da Vinci was introduced, the Palm Treo smartphone was the most advanced cell phone around. The iPhone was introduced in 2007 and by 2009 the iPhone 3G was the most popular smart device. In 2014 the iPhone 6 was introduced which coincided with the fourth generation of the da Vinci.



As the technology became more widely available, the research on various procedures flourished as well. More and more institutions and hospitals are now using this platform and publishing their results. It is estimated that in 2004 only about 10% of prostate cancer surgeries were performed with the da Vinci system. in 2017 nearly 90% of surgeries were performed with the robot. The same trend is witnessed in gynecologic and general surgery procedures.



Benefits of Robotic Surgery

As with laparoscopic surgery there are inherent benefits to minimally invasive surgery. Smaller incisions, less pain, shorter hospital stays, which all translate to faster return of patients to their normal activities. There are also less complications such as wound infections. However, there is an upfront cost associated with acquiring these latest technologies, which has hospitals scrambling for funds to provide the most cutting edge treatments to patients.


Benefits of Robotic vs. Laparoscopic Surgery

Conventional laparoscopy has defined advantages. It is well established, affordable, and available at most hospitals. It also provides some tactile feedback to the surgeon who can sense how much pressure he is putting on various tissues, but the disadvantages are plenty. One looses 3D vision, dexterity is compromised, motions are limited (up/down, left/right), there is the fulcrum effect, and tremors are significantly amplified.



Robotic surgery has taken all of the above disadvantages and turned them into strengths. The da Vinci robot and console provide 3D and HD vision. It allows for wristed motion and therefore provides greater mobility than the human hand. It also provides the surgeon with a very ergonomic console that prevents wear on the operator in the long-term.


Here are two videos comparing the same step in a radical prostatectomy (removal of the prostate gland) due to prostate cancer. The first video demonstrates suturing of the bladder neck to the urethra after the prostate gland has been removed. The motions are clearly hindered by the inherent weaknesses of laparoscopic surgery. The same step of a similar surgery is demonstrated in the second video. However, this time it is performed with the da Vinci surgical robot. The difference is quite obvious.



The above videos give a nice comparison between the benefits of robotics vs. laparoscopic surgery. In the #RoboticSurgery video Dr. Shakuri-Rad is demonstrating the smooth motions that the robot provides. One can also see that there is less blood in the field, and that a large blood vessel was preserved on the right side.


The typical setup for a robotic operating room is shown in the picture below (courtesy Intuitive Surgical). It consists of the operating room table, one or two bedside assistants, multiple monitors, and two surgical consoles. Once the surgeon places the robotic ports and connects them to the robot, he or she moves to the console and is able to start the surgical procedure.


Robotic Surgery
Typical set up in a robotic surgical OR

The console allows for an ergonomic sitting position, provides HD and 3-D vision, and allows the surgeon to move the laparoscopic instruments inside the body with ease and great accuracy.


Da Vinci Robot Console
Surgeon Console

Smooth Motions
Motions of the hand are replicated

The da Vinci Robot also allows for integration of advanced technologies such as the Firefly feature. This feature consists of injecting a dye called Indocyanine Green (ICG) intravenously and by turning a special camera feature on, the surgeon can differentiate tumor from normal tissue. Dr. Shakuri-Rad uses this technology to perform partial nephrectomy or the removal of kidney tumors while preserving normal tissues. In healthy renal parenchyma the transporter bilitranslocase binds ICG and healthy tissue appears isoflurescent when perfused with ICG laden blood (normal tissue turns green). Kidney tumor is deficient in bilitranslocase and therefore appears hypofluorescent (remains dark).


ICG
Firefly Feature

ICG Firefly
Intra-operative view with Firefly

Below is a video of Dr. Shakuri-Rad using the Firefly feature to plan his operative incision around a kidney tumor.



Robotic surgery can be a very effective tool in experienced hands. One has to also look at patient outcomes to ensure that the technology is being used appropriately. In the field of Urology, Robotic Assisted Radical Prostatectomy for prostate cancer (#prostatecancer) is one of the most common procedures in the US. Several studies have looked at the outcomes of robotic vs. open prostatectomy. The results have been consistently favoring the advanced robotic approach due less complications such as reduced blood loss, and faster recovery times for the patients. Patient's urinary and sexual function has also been shown to recover faster using the robotic approach. Although long term outcomes may be similar in some studies, we are able to spare the patient the traditional early post operative morbidity. Here is a video of one of Dr. Shakuri-Rad's robotic prostatectomy cases:



Dr. Shakuri-Rad also performs complex kidney stone surgery using the da Vinci robotic system as illustrated in the following video:



If you have been diagnosed or are concerned about urological problem and would like to pursue advanced minimally invasive treatment, contact us for an appointment to discuss your unique case.

 

References:

  1. Kelley WE. The evolution of laparoscopy and the revolution in surgery in the decade of the 1990s. JSLS. 2008;12(4):351-7.

  2. Lanfranco AR, Castellanos AE, Desai JP, Meyers WC. Robotic surgery: a current perspective. Ann Surg. 2004;239(1):14-21.

  3. Dobbs TD, Cundy O, Samarendra H, Khan K, Whitaker IS. A Systematic Review of the Role of Robotics in Plastic and Reconstructive Surgery-From Inception to the Future. Front Surg. 2017;4:66.

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