Robots in Medicine

Resource Post for August

Do robots have a place in our health care system? Can they ever take the place of health care professionals? Here are the latest updates in robot-assisted surgery

The Da Vinci Surgical System

The Da Vinci Surgical System is a US FDA approved medical instrument for endoscopic procedures. Endoscopy is a minimally invasive intervention using an endoscope. In the case of the Da Vinci System, the endoscope is computer assisted. The surgeon does not stand next to the operating table but sits in a console and manipulates the movement of the robotic arms in a process called telemanipulation. This is what is called manned robotic surgery and in theory, the surgeon can be doing telemanipulation from the next room or from thousands of miles away. However, current practices require the surgeon to be close by. The Da Vinci System is not new.

In use, a surgeon sits at a console several feet away from the operating table and manipulates the robot’s surgical instruments. The robot has three hands attached to a free-standing cart. One arm holds a camera (endoscope) that has been passed into the patient through small openings. The surgeon operates the other two hands by inserting fingers into rings.

The arms of the system using the EndoWrist technology – simulation the bending and twisting of human wrists

The da Vinci is intended to assist in the control of several endoscopic instruments, including rigid endoscopes, blunt and sharp dissectors, scissors, scalpels, and forceps. The system is cleared by the FDA to manipulate tissue by grasping, cutting, dissecting and suturing. It can be used in a wide range of surgical procedures from laparoscopic surgery to a heart bypass. Recently, it has been popularly used in prostatectomy, a procedure which requires precision in order to preserve urinary and sexual function. The Da Vinci system is manufactured by Intuitive Surgical, Inc. of Sunnyvale, California.

According to a recent estimate, there are about 1000 da Vinci systems in the world, mostly in the US and Europe.

The ZEUS Surgical System

Like the Da Vinci system the Zeus system has also been approved by the US FDA. Whereas Da Vinci has been cleared for cutting and suturing, Zeus is intended for grasping, holding, and moving things only. However, Zeus has one major advancement: it responds to voice commands.

ZEUS has three robotic arms that are mounted on the operating table. One robotic arm is called the Automated Endoscopic System for Optimal Positioning Robotic System (AESOP). AESOP is a voice-activated robot used to hold the endoscope. The FDA cleared AESOP to hold and position endoscopes in 1994, and voice activation was added later. ZEUS differs from the da Vinci system in that the AESOP part of ZEUS responds to voice commands. For example, a surgeon might say: “AESOP move right.” The positioning arm then would move right until the “stop” command was given. It is mainly used to control blunt instruments such as graspers and stabilizers during laparoscopic and thoracoscopic interventions. Zeus is manufactured by Computer Motion, Inc. of Goleta, California.

CyberKnife® Stereotactic Radiosurgery System

The Cyberknife system is a more recent development in robotic-assisted surgery that combines robotics with image-guidance technology. Unlike the previous two, Cyberknife is not used to cut, open, or grasp tissues. Instead, it works with an “accurately targeted megavoltage X-radiation” that is ideal for destroying malignant tumors and lesions in all locations of the body.

CyberKnife® is a nonsurgical, painless technology that can reduce or eliminate certain lesions and tumors, many previously considered inoperable anywhere in the body. A sophisticated robotic radiosurgery system, CyberKnife can also offer significantly fewer complications and lower risk than open surgery.

Cyberknife has the advantage of being non-invasive and painless and therefore does not require anesthetics. It has been cleared by the US FDA to assist doctors in radiotherapy of tumors in all parts of the body. It is estimated that there are more than 150 Cyberknife systems installed all over the world.

So what are the advantages of robotic-assisted surgery?

Precision

Robotic arms are capable of performing tasks to precision. For one thing, the arms are rock-steady without any tremors. They use smaller instruments which can more effectively operate small organs, including those in tiny infants. Robotics also offers motion scaling, which means that a surgeon’s gross hand movements can be reduced to fine movements, allowing for accuracy in tight spaces.

Minimal Invasiveness

Because the robotic arms of the Da Vinci and Zeus systems can operate even in tight spaces, cuts and openings need not be as large as in conventional surgery, minimizing complications, infections, and scarring. In the case of heart patients, for example, instead of an open chest procedure, robotic-assisted heart surgery can be performed through small incisions between the ribs. This results in lesser complications and faster recovery time. In the case of the CyberKnife, cutting is not necessary to remove tumors.

What stands in the way of robotic-assisted surgery?

Cost

Not all hospitals and clinics can afford a Da Vinci or a CyberKnife. The da Vinci system costs about $1 million, the ZEUS $975,000. That is why the use of robotic-assisted surgery is not so widespread.

Training

It takes a well-trained medical professional to operate a surgical robot, well-trained, not in only in surgery but in operating robotic devices. It takes time before a doctor feels fully confident in using a surgical robot and it is something that is learned at med school. A training program costs time and money. According to Dr. Paul Massimiano of Inova Fairfax Hospital “More than this being a hard technique to learn, it requires adjusting your approach to the surgery and your way of thinking. The robot is your assistant now, and that takes some getting used to.”

Acceptance

It takes getting used to be operated on by a machine. Resistance to the idea of robotic-assisted surgery is not only common among patients but among doctors as well. According to Randolph Chitwood Jr., M.D., chairman of the department of surgery at East Carolina University in Greenville, N.C

“There is a mental challenge of moving from a large incision where you can directly see things and touch the patient to operating through small incisions with less direct control. But I tell surgeons they have even more control because the robot is more precise. It’s a matter of accepting that you don’t have to see with your eyes directly. You can look through a scope.”

Is robotics the future of medicine?

Currently, robotic-assisted surgery hasn’t gone mainstream and is still considered an experimental technique in some countries. However, as acceptance increases and cost decreases, its application may become widespread. However, it is unlikely that robots will completely replace human doctors anytime soon. They will be there to assist but in the end, the surgeon should always be in control.

Video: www.youtube.com/watch?v=Fk5pCWgNyPk

Photo: wikimedia commons; stock.xchng