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Dr Amani Harris

Introduction to Gynaecological Robotic surgery

Robotics Laparoscopy

Abdominal Vaginal

Leonardo da Vinci 1452-1519self-portrait (circa 1512 to 1515)

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Open surgery techniques

Laparoscopic (Keyhole) Surgery

Robotic Surgery

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+What is Robotic Assisted Surgery?

Robot is a newer generation surgical tool to assist surgeons in performing surgery.

It is not changing the basics of Surgery.

Robotic assisted surgery is not something new, this idea has been floating for decades.

+Robotic Knight – 15th Century

Model of a robot based on drawings by Leonardo da Vinci.

On display in Berlin Museum.

+ Important timelines:

1985PUMA 560 system: placing a needle for brain biopsy using CT guidance

1988 PROBOT: Prostrate surgery

1992 ROBODOC: used to assist hip replacement

1997 da Vinci Robot: Tubal re-anastmosis

1999 Robotic Assisted Coronary Bypass

2001Tele-Surgery: Cholecystectomy, Surgeon in New York; Patient at Strasburg

2005 da Vinci Robotic Assisted Hysterectomy

+What is a Surgical Robotic?

Passive Autonomous Assistive

Active Actively control the instruments ( master –

slave manipulators) Eg: Da Vinci, Aesop,

+Currently Available Robotics

AESOP: robotic camera holder

Da Vinci Robot: integrated immersive system

+Active Robots - terminology

Immersive

Haptics

Tele operative

Tele presence

Telementoring

Telestration

+Active Robots – da Vinci Surgical System

Utilizes advanced technology to assist surgeons with operations

Decreases the need for open Surgery

Does NOT act on its own

All movements are controlled by the surgeon

System has a 3D high definition vision – can be magnified up to 10 times

Instruments have mechanical wrist that bend and rotate to mimic the movements of the human wrist.

? Improves patient outcomes

+Evolution of Surgery

Evolution of Da Vinci Robot

1995 Intuitive Surgical was founded

1999, The first da Vinci System was introduced to market

2000 US FDA cleared da Vinci for laparoscopic surgery

2003 first major upgrade - 4th instrument arm

2006 da Vinci S System

+ Evolution of Da Vinci Robot - Standard System

+da Vinci Robot

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2006 ‘S’ system

Evolution of Da Vinci Robot

2009 da Vinci ‘Si’ system

+The Da Vinci Robotic System

Surgeon Console

Surgical Cart

Patient Cart

+ The Console

3-D Vision

Filtered tremors 7degrees of freedom Multi-task

+ The Console – Intuitive hand motions

+ Patient’s cart -Robotic surgical arms

+ Endo-Wrist Instruments & telescope

+Instruments & Operative view

+ Robotic Surgery

Advantages Disadvantages

Ergonomic

3-D Vision

Filtered tremors

Improved dexterity; 7

degrees of freedom

Less fatigue

Allows performing

complex procedure

Lack of tactile feedback

Can’t change operating

table position once arms

are docked to patient

Set up time

Cost

Capital cost

Maintenance

Disposables

+Training in Robotic Surgery

+Training

20 -40 hours on the simulator

Achieve scores on >85-90% on all tasks

Dry lab – 1 full day session Docking on dummies Types of docking

Wet Lab – Pig lab 1 full day session Operate on anesthetized pigs Port placement and docking Perform surgeries such as ureterolysis, Nepherectomy, etc

+Credentialing

Perform 3 major surgeries supervised by a recognized Proctor

Some hospitals require you to do 5 cases

Perform a minimum of 20 cases per year to maintain your accreditation

You will be listed as a robotic surgeon on the global da Vinci website

You can be a Proctor once you have completed 50 cases

+Issues with Training and accreditation

Access is an issue

Trainers are still learning

What is the safest and best way to learn?

What is the learning curve?

How many cases required per year to maintain proficiency? At least 20 per year…1 per fortnight!

+ Robotics - FDA

+What does Intuitive say about the da Vinci Robotic Surgical experience?

+What does Intuitive say about the da Vinci Robotic Surgical experience?

+What does RANZCOG say about Robotic Surgery?

+What does RANZCOG say about Robotic Surgery?

+What does RCOG say about Robotic Surgery?

Another clear advantage of robotic surgery is that fewer errors are made than with straight-stick surgery says the review.

A recent review of hysterectomies compared operations conducted by robotic surgery and laparoscopic surgery. The results showed that robotic surgery was quicker, reduced the hospital stay of the patient and resulted in less blood loss

+What does ACOG say about Robotic Surgery?

The outcome of any surgery is directly associated with the surgeon’s skill. Highly skilled surgeons attain expertise through years of training and experience. Studies show there is a learning curve with new surgical technologies, during which there is an increased complication rate.

Robotic hysterectomy generally provides women with a shorter hospitalization, less discomfort, and a faster return to full recovery compared with the traditional total abdominal hysterectomy (TAH) which requires a large incision. However, both vaginal and laparoscopic approaches also require fewer days of hospitalization

+Robotics – Evidence: Sacro-Colpopexy

Courtesy of intuitive

+ Robotics – Evidence: Myomectomy

575 cases RAM (15%) LM (16%) AM (68%)

Weight 223gm 96.6gms 263gms

Blood loss 150mls 100mls 200mls

Time 181 mins 155 mins 126 mins

Stay in hospital (days)

1 1 3

Conclusion: Robotic-assisted myomectomy is associated with decreased blood loss and length of hospital stay compared with traditional laparoscopy and to open myomectomy. Robotic technology could improve the utilization of the laparoscopic approach for the surgical management of symptomatic myomas.

+ Robotics – Evidence: Myomectomy

Conclusion: RLM has significant short-term benefits compared with AM and no benefits compared with LM. Long-term benefits such as recurrence, fertility, and obstetric outcomes remain uncertain.

+Where is Robotic surgery heading?

Single site surgery

+Where is Robotic surgery heading?

Single site surgery

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Augmented Reality

Real time data fusion

Courtesy: CBYON

Robotics; Future directions

Courtesy of Intuitive

+ Robotics; Future directions

Courtesy of intuitive

+ Robotics; Future directions

Courtesy of intuitive

+Remember

A robot is only as good as its operator.

If you are not a good surgeon, Robotic surgery is not going to make you into one.

Similarly, Robot is not going to make you a fantastic laparoscopic surgeon.

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+Remember

One still needs to understand the principles of Laparoscopy.

Robotic assisted surgery is not here to replace Laparoscopic surgery.

Robotic assisted surgery has its place with complex surgeries Complex hysterectomies Grade 4 endometriosis Sarco-colpopexy

+Thank you – Video to follow

Image courtesy: Intuitive

Intuitive website & http://www.davincisurgery.com

Uptodate

J Minim Invasive Gynecol. 2013 May-Jun;20(3):335-45. doi: 10.1016/j.jmig.2012.12.010. Epub 2013 Feb 27. Robotic-assisted laparoscopic vs abdominal and laparoscopic myomectomy: systematic review and meta-analysis.Pundir J1, Pundir V, Walavalkar R, Omanwa K, Lancaster G, Kayani S.

Obstet Gynecol. 2011 Feb;117(2 Pt 1):256-65. doi: 10.1097/AOG.0b013e318207854f.Robotic-assisted, laparoscopic, and abdominal myomectomy: a comparison of surgical outcomes.Barakat EE1, Bedaiwy MA, Zimberg S, Nutter B, Nosseir M, Falcone T.

RANZCOG

RCOG

ACOG

References