Advancing Technology of Medicine: The Da Vinci Robot

Richard Ly

10/18/13

Professor Wolcott

In this paper, it will discuss the advantages of robot-assisted Laparoscopies with the

Da Vinci robot when compared to conventional laparoscopic surgeries or laparotomies. It

will go over the information of the actual surgical procedure; however, it will not go into

great detail as that is not the reason for this paper. Sources used in this will date from 2005

to the present. The reason for this is to briefly show the first model of the Da Vinci robot.

In that article, it states problems and complications the first model went through and most

of the articles most recently published will explain the advancements of the Da Vinci robot

and techniques involving it. Within the sources used for this annotated bibliography, most

of the authors are employees of hospitals, more specifically in the Department of Surgery

or subgroups of Minimally invasive surgeries. Other authors were electrical engineers.

Credibility depended on the authors' degree as well as the institution of their employment.

This paper would best help a person who will be or could be undergoing robot-

assisted laparoscopic surgery as it may help inform the patient to be more knowledgeable

of this new technique used in surgery. It would also be beneficial to students in high school

or college that may interested in general medicine. This paper could also be interesting to

an engineer major that could be specializing in medical technology. This paper, due to the

terms used, decreases the possible audience.

Although difficult, it is not impossible so a high school student would be able to

understand the what each part of the annotation is implying. A few terms that may aid the

reader to have a better understanding of the topic would be laparoscopies-viewing of the

abdomen via fiber optic instrument to aid the surgeon in doing a procedure-, morbidity-

percentage of a patient's chance of receiving a disease- , and carcinoma-cancerous tumor-.

After reading this paper, it gives a broad understanding of the advantages of robot-assisted

surgeries over conventional surgeries.

Anderson, Casandra. Joshua Ellenhorn, Minia Hellan, Alessio Pigazzi. "Pilot Series of

Robot-Assisted Laparoscopic Subtotal Gastrectomy With Extended

Lymphadenectomy For Gastric Cancer." Springer Link. 8 March 2007. 18 October

2013. In this article, a team of four doctors from the Department of Surgical

Oncology of the City of Hope discuss the technique of robot-assisted laparoscopic

surgery to remove carcinogenic tumors of the lymph nodes. For this study, 7 cases

(3 females and 4 males) underwent laparoscopic subtotal gastrectomy with

omentectomy and robot-assisted extended lymphadenectomy. For this, surgery took

approximately 420 minutes and were completed successfully without conversion-

reverting back to the conventional method. There was, however, one complication

due to one of the patients requiring a colon resection for a devascularized segment.

After performing this case study, the team concludes that the technique of robot-

assisted surgery to remove tumors of the lymph nodes is feasible. In result, the

patients have a higher chance of shorter hospital stay post-op and lower morbidity

rate. What becomes a problem with this case study, however, is that the results are

short term and when dealing with carcinomas, long-term results are extremely

important and, at this time, are not available. When comparing the robot-assisted

laparoscopies and the conventional laparotomies, the robot-assisted laparoscopies

provide an improved amount of dexterity for the surgeon as well as increased

freedom within the surgical site, no surgeon tremor, and more precision in the

procedure.

Antoniou, Starvros A. George A. Antuniou, Oliver O. Koch, Rudolf Pointner, Frank A.

Granderath. "Robot-assisted Laparoscopic Surgery of the Colon and Rectum."

Springer Link. 20 August 2011. 18 October 2013. In this article, the authors,

Stavros A. Antoniou, George A. Antoniou, Oliver O. Koch, Rudolf Pointner, and

Frank A. Granderath, review the robot-assisted laparoscopic surgery within the

colon and rectum. These authors are all employed within different hospitals, one of

which works in the Center for Minimally Invasive Surgery. The article focuses on

the improvements in surgery as well as postoperative oncologic outcomes although

since studying the oncologic outcomes are more long-term, the material available is

minimal. The authors explain that the use of the robot had a low percentage of

complications during the procedure of the colectomies. Even with the time to set up

the robotic system, the amount of time to perform the procedures with the assistance

of the robot is reasonable. Robot-assisted surgeries allow the surgeon to take

advantage of numerous benefits: advanced degrees of freedom, the magnifying

camera effect, a stable camera platform, and the 3-dimmensional imaging. With the

potential of increased precision, the surgeon is able to decrease the amount of nerve

loss within certain surgeries. Even with this growing technology becoming a norm

in the surgical field, it still is in its infancy. Certain procedures, such as a splenic

flexure mobilization, are not yet feasible since the robot system is unable to reach

the left upper abdomen. The patients movement during a surgery also becomes

extremely limited, thus limiting the use of the robot in other surgeries where this is

required. Although the Da Vinci Robot is still in its infancy, it still provides many

benefits to the surgeon when performing procedures where increased dexterity will

greatly improve the patient's outcome.

Advincula, A. P. "Surgical Techniques: Robot-assisted Laparoscopic Hysterectomy With

The Da Vinci Surgical System." The International Journal of Medical Robotics and

Computers. Volume 2, Issue 4, 15 December 2006: pages 306-311. In this article,

the author, A.P. Advincula- a member of the Department of Obstetrics and

Gynecology of the University of Michigan- discusses the technique of robot-assisted

surgery with use in laparoscopy hysterectomies. Although using the Da Vinci robot

in performing a laparoscopic hysterectomy provides numerous advantages such as

increased dexterity and precision, laparotomy hysterectomies is still the most

common technique used. Robot-assisted surgeries offers the ability to perform an

almost suture-less hysterectomy due to the improvements in the robot's energized

instrumentation.

Bodner, Johannes. Paolo Lucciarini, John Fish, Reinhold Kafka-Ritsch, Thomas Schmid.

"Laparoscopic Splenectomy With The Da Vinci Robot." Journal Of

Laparoendoscopic & Advanced Surgical Techniques. Volume 15, Number 1, 1

February 2005: pages 1-5. The contributing authors of this journal article are all

Doctors of Medicine. This article explains the early stage of the Da Vinci robot. In

the earlier model of the Da Vinci robot, it required two people to use the robot in

surgery: one at the console and one at the tableside controlling the robot. This study

was based on splenectomies using only the Da Vinci robot by the same surgeon. In

the article, the authors note that a previous paper by Talamini stated that

splenectomies wouldn't be an ideal procedure to be done with the robot since 2 of 7

splenectomies were forced to convert back to the conventional method. However,

the authors of this article report that none of the splenectomies ran into any

complications in surgery. Past research stated that the size of the spleen would

greatly impact the results of the surgery, however, the first splenectomy performed

in their study was an abnormally oversized. Even with this, the surgery was still

done without any complications. In the discussion section, the authors note that,

when studying these 7 consecutive cases, the results were ideal: no surgical

complications and excellent short-term remission rates. The authors also state that

within a few years advancements will occur to the point where only one person will

be needed to operate the robot.

Eisenberg, Dan. Tamas J. Vidoszky, James Lau, Bernadette Guiroy, Homero

Rivas."Comparison of Robotic and Laparoendoscopic Single-site Surgery Systems

in a Suturing and Knot Tying Task." Springer Link. 27 February 2013. 18 October

2013. The authors of this article, Dan Eisenberg, Tamas J. Vidovszky, James Lau,

and Homero Rivas, are all members of the Department of Surgery within their

hospital. In this article, the authors conducted a study based on the comparison

between the two different techniques of laparoscopies: Laparoendoscopic Single-

Site (LESS) surgery and the use of the Da Vinci Robot. To compare the two, the

authors gave five minimally invasive surgeons the task to suture and tie a square

knot with both techniques. These surgeons all have previous experience in LESS

surgery as well as similar single-site surgeries more specialized to their practice.

The surgeons received some formal training with the Da Vinci robot when arriving

at the site; however, before this, none of the surgeons had personal experience

purely with the robot in their practices. To measure the quality of the work, the

sutures were tested with a "leak" test where saline would be injected into the suture

with a syringe and have pressure be put onto it. When performing the test, the

results showed that 100% of the surgeons were able to complete the task within the

20minutes mark when using the robot whereas only 20% of the surgeons were able

to complete it within the 20minutes mark on their first try. Not only that, however,

but the sutures done with the robot actually had no leaks when tested and 90% of the

sutures done without the robots did leak. During this study, the authors noted that

this comparison of the two different techniques was based on the performance of the

task. With that, it is easily shown that the use of the robot did increase time

efficiency as well as quality of the sutures; however, the Da Vinci robot takes a large

amount of time to set up for the procedure and the time that was recorded only

involved the time of the task.

Friedman, Diana W. Thomas S. Lenvay, Blake Hannaford. "Instrument Failures For the Da

Vinci Surgical System: a Food and Drug Administration MAUDE Database Study."

Springer Link. 14 December 2012. 18 October 2013. In this article, the authors,

Thomas S. Lendvay-a member of the Department of Urology at the University of

Washington-, Diana C. W. Friedman and Blake Hannaford- both members of the

Department of Electrical Engineering at the University of Washington- discusses the

instrument failures of the Da Vinci robot. To do this, the team uses the FDA

database to review the reported cases of system failures of the Da Vinci robot. From

what the FDA Database shows, wrist or tool-tipped failures are most commonly

reported, cauterizing instruments follow next, then it would be instrument shaft, and

lastly would pertain to the cable and housing. Although this may be what is shown

on the FDA database, it is not 100% accurate since it is was is "reported"; there is an

unknown amount of cases of system failures that go unreported at the hospital's

discretion. Even if the hospital would report any known malfunctions of the Da

Vinci system, there is still a good percentage of system failures that the surgical

team may not notice. Perhaps the reason the instrument's wrist or tool-tip has the

most failures is because it's what would most be noticeable since the surgeon's

vision is always focused on the instruments.

Hagen, Monika E. Oliver J. Wagner, Ihsan Inan, Philippe Morel, Jean Fasel, Garth

Jacobsen, Adam Spivack, Kari Thompson, Brian Wong, Lauren Fischer, Mark

Talamini, Santiago Horgan. "Robotic-Single Incision Transabdominal And

Transvaginal Surgery: Initial Experience With Intersecting Robotic Arms." The

International Journal of Medical Robotics and Computer Assisted Surgery. Volume

6, Issue 3, 19 April 2010: pages 251-255. In this article, the team of doctors from

the Center for the Future of Surgery of the University of California and the Division

of both the Anatomy and Digestive Surgery of the University Hospital Geneva,

Switzerland review the technique of robot-assisted single-incision in both

transabdominal and transvaginal surgeries. In this case study, the doctors perform

the surgeries on male and female human cadavers. Performing robot-assisted

transabdominal laparoscopy was successful. During this, the surgeon uses the

"chopstick" method, crossing the left and right instruments of the Da Vinci robot to

prevent collision and increase movement within the surgical site. When doing this,

the surgeon notices a slight loss of range with the left instrument due to the third

instrument (the camera). The surgery was successful without any problems in the

cadaver. When performing the robot-assisted transvaginal laparoscopy, it was shown

that it was not feasible due to the constriction of the vagina and the limited space

between the thighs. Although this may not be completely accurate when comparing

to a living human since the cadaver has limited space both inside(inflated bowel)

and outside (between thighs) as well as suboptimal bedding, resulting in difficulty in

the set up of the surgery.

Joseph, R.A. Salas N.A., C. Johnson, A. Goh, S.P. Cuevas, M.A. Donovan, M.G. Kaufman, B.

Miles, P.R. Reardon, B.L. Bass, B.J. Dunkin. "Chopstick Surgery: A Novel Technique

Enables Use of the Da Vinci Robot To Perform Single-Incision Laparoscopic Surgery."

Surgical Endoscopy. Volume 24, Issue 12. December 2010: Page 3224. The contributing

authors to this article explain the improvements of the Da Vinci robot. Before the

"chopstick" technique was incorporated into the Da Vinci robot, the surgeon would run

into minor complications of the instruments of the robot colliding with one another inside

the patient as well as outside. With the use of this technique, not only did it eliminate the

collision of instruments, it also greatly increased the range of motion within the surgical

site of the patient.

Kang, Chang Moo. Dong Hyun Kim, Woo Jung Lee, Hoon Sang Chi. "Conventional

Laparoscopic and Robot-assisted Spleen-Preserving Pancreatectomy: Does Da Vinci

Have Clinical Advantages?" Springer Link. 7 December 2010. 19 October 2013. In this

article, the team of doctors -of the Division of Biliopancreas of Yonsei University

College of Medicine, the Clinic of Pancreatic and Biliary Cancer of Yonsei University

Health System, and the Department of Surgery of Yonsei University Wonju College of

Medicine of Seoul, Korea- discuss results of their case study of the use of the Da Vinci

Robot in Pancreatomy to remove any tumors while preserving the pancreas. In this case

study, the team obtains two group of patients that require this surgery. When asking the

patients of which type of surgery they would want, the younger patients leaned toward

the robot-assisted surgery whereas the older patients were more towards the conventional

route. When the surgeon performed the procedure, the patients that underwent robot-

assisted surgery had a significantly greater amount of their pancreas when compared to

the patients that received the conventional surgery. The better results of the robot-assisted

surgery is because of the advantages it gives the surgeon. With it, it provides a 3-

dimmensional view, wrist-like movement of the instruments, no tremor, and scale

adjustment of the instruments as well. Although the results were much better with the

patients that received robot-assisted surgery, the cost of this technique exceeded twice the

cost of conventional surgery. Before the Da Vinci robot, performing this type of

procedure effectively, the surgeon would need a great amount of experience but now with

the robot, it takes a substantially shorter amount of time to learn this procedure.

Kerbl, David C. Jason Y. Lee, Phillip Mucksavage. "The Da Vinci Surgical System Overcomes

Innate Hand Dominance." Journal of Endourology. Volume 25, issue 8. August 2011:

page 1385. The contributing authors of this article explain the disappearance of innate

hand dominance when using the Da Vinci robot. In this case study, the authors obtain

multiple volunteers of all levels of experience with robot-assisted surgery. Everyone was

given a basic tutorial on operating the robot, regardless of the experience. The volunteers

were then given 30 minutes to practice basic tasks with the robot. Afterwards, their

manual dexterity was tested first, and later was again tested with the robot. When

comparing the results of the tests, the first test showed significant differences with the

majority of the people of the level of dexterity of each person where as the use of the

robot almost completely eliminated the gap between each hand.

Pedraza, Rodrigo. Madhu Ragupathi, Tara Martinez, Eric M. Haas. "Robotic-assisted

Laparoscopic Primary Repair of Acute Iatrogenic Colonic Perforation: Case

Report." International Journal of Medical Robotics and Computer Assisted Surgery.

Volume 8, Issue 3. 20 June 2012: pages 375-378. The contributing authors of this

article are doctors that are part of either the Division of Minimally Invasive Colon

and Rectal Surgery of the University of Texas Medical School or the Colorectal

Surgical Associates LLP of Houston, Texas. In this article, the team of doctors

describe a case study of repairing a perforation that was caused by a colonoscopy

with the technique of robot-assisted laparoscopy. During a colonoscopy, the chance

to have a perforation is 0.016-0.2%. When this does happen, it is very serious and

would most commonly be repaired by doing a laparotomy. Now with the Da Vinci

robot, surgeons are able to repair perforations and, in result to using the robot, the

patient will have less time spent in the hospital post-op with a lower morbidity rate

and lower chance of infection during the procedure. The use of the robot allows the

surgeon to have improved dexterity, stable camera platform, 3-dimensional

visualization with the capability of 10 fold magnification. The surgeon also has

increased range of motion within the site and no "surgeon tremor". The article

describes one situation where the use of the Da Vinci robot is ideal since

conventional techniques of laparoscopies wouldn't be possible with the special

characteristics of the perforation. With the assistance of the robot, the surgeon was

able to maneuver throughout the abdomen with ease. The improved camera allows

the surgeon to spot the problem out quicker and fix anything else around it that the

tear affected.

Pineda-Solis, Karen. Heriberto Medina-Franco, Martin J Heslin. "Robotic Versus Laparoscopic

Adrenalectomy: A Comparative Study In a High-Volume Center." Springer

Science+Business Media (2012) Web. October 9, 2013. A team of doctors -from the

Department of Surgery of both Instituto Nacional de Ciencias Medicas y Nutricion

Salvador Zubiran, Mexico and the University of Alabama, and the Section of Surgical

Oncology of the University of Alabama- compare the two types of laparoscopic

surgeries: robotic-assisted and conventional. The doctors used two groups of patients that

underwent the same type of surgery: adrenalectomy, the removal of the one or both of the

adrenal glands. One group undergoes robot-assisted adrenalectomy (RA), while the other

group of patients receive laparoscopic adrenalectomy (LA). When comparing the two

groups, the group that underwent the RA had a shorter amount of time in the hospital

post-op and a shorter recovery time compared to LA. During LA, there is a higher chance

of infection for the patient since the incision is significantly larger compared to the

incision done in RA. When performing LA, there is also a higher chance of mistakes

since it requires two people to perform this procedure: one to hold the camera and guide

the surgeon and one to perform the actual procedure. LA also has a limitation of

movement for the surgeon. Although in the case study, the lower chance of infection and

other benefits of RA are traded for time of the procedure; RA, when compared to LA,

takes longer.

Ragupathi, Madhu. Diego I. Ramos-Valadez, Rodrigo Pedraza, Eric M. Haas. "Robotic-

Assisted Single-Incision Laparoscopic Partial Cecectomy." The International

Journal of Medical Robotics and Computer Assisted Surgery. Volume 6, Issue 3. 27

July 2010: pages 362-367. In this article, the team of doctors describe a case study

with the use of the Da Vinci robot to perform a single-incision laparoscopic partial

cecectomy. In this case study, the doctors use a 53 year old male. The patient was

presented with a tubulovillous adenoma and provides consent to undergo the

robotic-assisted surgery. The surgery is completed without any complications

occurring within the patient. In this case study, the surgeon uses the "chopstick"

technique to cross the two instruments of the Da Vinci robot to prevent collisions

within or on the outside site of the patient of the surgery. This also increases the

range of movement for the surgeon. Although this technique provides great cosmetic

benefits of a small incision, it benefits the surgeon as well. With the use of the

robot, the surgeon is able to move more freely within the site of the surgery and has

improved dexterity when performing the surgery. The surgeon is also able to

overcome restrictions that conventional laparoscopic surgeries would face.

Spinoglio, Giuseppe. Luca Matteo Lenti, Valeria Maglione, Francesco Saverio Lucido, Fabio

Priora, Paolo Pietro Bianchi, Federica Grosso, Rual Quarati. "Single-Site Robotic

Choecystectomy (SSRC) versus Single-Incision Laparoscopic Cholecystectomy(SILC):

Comparison of Learning Curves. First European Experiences." Springer Link. 17

December 2011. 18 October 2013. In this article, the doctors of the Department of

Surgery of SS Antonio e Biagio Hospital, Unit of Minimally Invasive Surgery of

European Institute of Oncology, and the Department of Oncology of the SS Antonio e

Biagio Hospital compare single-site robotic cholecystectomy (SSRC) and single-incision

laparoscopic cholecystectomy (SILC). When performing SSRC, no major complications

occurred during the procedure and there was no need of a conversion to the conventional

method either. When the surgeon uses the technique of SILC, a major disadvantage is

present that the Da Vinci robot is able to overcome: intuitive control. Unlike SILC, SSRC

gives the surgeon an easier mobility of the instruments, resulting in an improved control.

When comparing the post-op status of the patients, the group of patients that underwent

SILC were required to stay at the hospital longer and also received a higher percentage of

morbidity. The use of SSRC increased satisfaction due to the smaller scar; cosmetically,

this is favorable.

Turchetti, Giuseppe. Ilaria Palla, Francesca Pierotti, Alfred Cuschieri. "Economic Evaluation of

Da Vinci-Assisted Robotic Surgery: A Systematic Review." Surgical Endoscopy.

Volume 26, issue 3. March 2012: Page 598-606. In this article, the contributing authors

use sources of people from the Institute of Medicine of Washington, and numerous

people within the field of health technology. This article discusses the economic side of

robot-assisted surgeries. This specifically focuses on the cost of the operating time and

hospital stay. From the articles the author uses to compare the cost between robot-assisted

surgery and conventional surgery, it shows that the cost of robotic surgery due to a longer

time in the operating room; however, the main factor in the cost would directly correlate

with the experience of the surgeon with the robot. Robot-assisted surgeries also result in

less days in the hospital post-op.