What is Robotic Surgery?

Robotic surgery is the use of robotic technology to perform complex surgeries. The most established is the da Vinci Surgical System which comprise of 3 components: a surgeon’s console, a patient-side robotic cart with 4 arms, and a 10 times magnified, high-definition 3D vision system (Fig 1). A common misconception is that the robot performs the surgery; the robot is not performing surgery; the surgeon does the surgery using the robot as the interface.

Fig 1a. Surgeon console

1b. Robotic arms in position        

1c.3D Vision camera

Robotic abdominal surgery is an enhancement of standard laparoscopic surgery as the operation is still performed through key-hole incisions in the abdomen. As opposed to standard laparoscopic surgery where hand-held rigid instruments are used, the robotic arms are flexible and mimic the surgeon’s hand and wrist movements, giving greater dexterity, superior strength and better precision (fig 2). These movements are intuitive in nature, i.e. the instrument tips move in the same direction as the human hand and reproduce the same movements as in open surgery. In addition, a filtration feature dampens any hand tremor to improve precision.

Fig 2. The robotic arm mimics human wrist movements

Robotic versus Standard Laparoscopy

Robotic laparoscopy has a shorter learning curve.  The combination of 3-D, magnified vision with endowrist, intuitive instrument movements make dissection and suturing so much easier for the surgeon. Although there is no tactile feedback on the robot, this is overcome by the superior vision. In standard laparoscopy, the surgeon has to overcome the limitation of rigid, counter-intuitive instrument movements. He also needs to have a regular, high patient load to maintain his laparoscopic skills. For long laparoscopic procedures, fatigue and muscle ache are bound to set in. On the other hand, the da Vinci robot allows the surgeon to sit comfortably in a chair while doing the surgery. This relieves physical fatigue and allows the surgeon to concentrate better.  After all, this is still laparoscopic surgery, just that it is now robotically-assisted.

Advantages of Robotic Surgery

Robotic surgery has been shown to improve patient’s recovery because of:

• Less pain
• Less blood loss
• Less scarring
• Less damage to surrounding structures
• Fewer complications

As a result, hospital stay is shorter and return to regular activities faster.

Application

Robotic surgery is useful in the fields of:

• Urology
• General Surgery
• Cardiac surgery
• Gynaecology
• Head & Neck surgery

For urology, the da Vinci robot enhances surgery for:

• Prostate Cancer
• Kidney Cancer
• Kidney pelvis obstruction
• Ureter stricture
• Bladder cancer
• Bladder-Vagina Fistula

because these surgeries are reconstructive in nature and require precise, water-tight suturing.

Prostate

Radical Prostatectomy

Radical prostatectomy is the removal of the whole cancerous prostate to achieve the best cure rate. Prior to the use of robotic surgery, prostatectomy surgery was done via a long open incision over the lower abdomen (Fig 3). Besides greater wound pain and slower recovery after surgery, the open method carried a high blood loss with blood transfusion rates up to 67%. With the robotic method, blood loss is minimal, usually less than 200 ml, resulting not only in negligible transfusion rate but also quicker recovery. Up to 90% of all radical prostatectomies in the United States are performed robotically. The situation in Singapore is the same and very few open prostatectomies are done here.

Fig 5. Incisions for open compared to robotic method

Robotic prostatectomy has become the single most popular robotic procedure because the small dextrous robotic arms and magnified 3-D view overcomes the limitations of operating in the narrow male pelvis. After removing the prostate, the bladder needs to be re-joined to the short urethra stump. This is the most difficult part of the surgery, even for the experienced laparoscopic urologist. The robot makes this task easier because the flexible arms make stitching intuitive and precise with the operator comfortably seated. The other concern which many patients have is the functional consequence of incontinence and impotence. Once again, the superior vision of the robotic system helps the surgeon to better identify and preserve the nerves and structures responsible for continence and erection. Meta-analysis report better cancer clearance, faster recovery of continence and potency compared to open and standard laparoscopy. Robotic prostatectomy is now the “gold standard” operation for prostate cancer.

Kidney

a. Pyeloplasty

Pyeloplasty is the surgical repair of an obstructed pelvi-ureter junction (PUJO). In this condition, the kidney is blocked at the junction due to a stricture or crossing vessel. This abnormal segment usually needs to be excised and continuity restored by stitching the disconnected renal pelvis to the upper ureter. The standard method is open surgery. Laparoscopic method is also feasible but takes a long time because of the limited stitching ability of the rigid instruments. The robot makes this stitching task easier, thanks to the dextrous arms. Centres are now reporting shorter operating times with success rates of > 98%; identical to open and standard laparoscopic methods.

b. Partial Nephrectomy

Nephrectomy is the removal of the whole kidney and performed mostly for kidney cancers > 4 cm in size. In total nephrectomy, there is no suturing involved. Hence, the outcome is similar to standard open / laparoscopic surgery. However, for tumours < 4 cm, partial nephrectomy is recommended so as to avoid or delay future kidney failure.  The disadvantage in partial nephrectomy is that a water-tight closure of the collecting system is crucial. The kidney defect also needs to be repaired to avoid excess bleeding. This whole task has to be done within 30 mins as the kidney can only tolerate a short period of interrupted blood supply. In standard laparoscopy, such a repair is a challenge because stitching is much more difficult to perform. Once again, the robot’s superior suturing capability helps the surgeon to close the defect within this time limit.

Ureter

Reimplantation

Ureter stricture consequent to injury or inflammation may not always be amenable to endoscopic means. In such a situation, re-implanting the obstructed ureter to another site in the bladder is the only way to unblock the kidney obstruction. Open surgery is the traditional method, but laparoscopic re-implantation will help avoid a long scar. Once again, the limitation with standard laparoscopic method is the stitching aspect, which is tedious and time-consuming. The robot with its intuitive and dextrous arms makes ureter reimplantation easier with greater precision and leak-proof.

Bladder

a. Radical cystectomy

Radical cystectomy is the removal of the entire bladder and this is mostly done for muscle-invasive bladder cancer. Open surgery is already a complex and long one fraught with excess bleeding. The robot’s superior vision and flexible arms makes dissection less bloody due to the superior, magnified vision of the blood vessels and structures around the bladder. Following removal of the bladder, the ureters are joined to a length of small intestine (ileal conduit) or a new bladder (neobladder) fashioned from a longer length of small bowel. The smaller incisions and less blood loss makes recovery faster and hospital stay shorter. However, an experienced team is needed for this kind of reconstructive surgery.

b. Gynae-urology

Pelvic floor reconstruction can be done robotically too. Vesico-vaginal fistula can similarly be repaired robotically with the advantage of better visualization and more precise suturing.

Summary

The robot has made minimally-invasive surgery a safer and technically superior one. Surgeons can now perform more “exacting surgery” thanks to enhanced vision and articulate instruments. The main disadvantage is lack of tactile feedback and the surgeon is remote from the operating table. Hence, it is important to have a regular team of trained assistants and nurses. The robotic surgical system is a high financial outlay; the set-up cost, maintenance cost and training requirements make it difficult for many hospitals to own a da Vinci robot.  Nevertheless, the evidence is clear that robotic surgery is superior to standard laparoscopic and equal to open surgery in many aspects. The trend now is for patients to travel to leading hospitals that offer robotic surgery despite its higher cost.