Surgery Robotics in Laparoscopy

Amanda Mayo

University of Toronto

MHSc Clinical Engineering (Candidate)

Overview

• Why Robot-Assisted Laparoscopy?

• Current Applications

• Current Systems

• OR set-up

• Issues and limitations

• Future possibilities

Problems with Conventional Laparoscopy

Laparoscopy has revolutionized surgery but has the following limitations:– Limited movement– Reduced from 6 to 4 degrees of freedom– Inability to perform high-precision sutures– Unnatural positions for surgeons– Flat vision (2D)

Robot-Assisted Laparoscopy

• Optical system and robotic arms with highly-specialized instruments connected to a computer- driven mechanism that is controlled by a surgeon

• Surgeon's hands and fingers direct the surgery and the movements are translated by the computer to precise movement of the microsurgical instruments inside the patient's body

Robot-Assisted Laparoscopy:Overcoming Limitations

• High quality, stable, 3D camera image• Tremor elimination• Scaled movements (more precise, smaller movements)• Robotic instruments have increased degrees of freedom (6 or 7

– 4 Motorized • Up and Down • In and Out • Shoulder: Back and Forth • Elbow: back and forth

– 2 Floating • Forearm: back and forth • Wrist

– 1 Fixed change in angle • Elbow Tilt (+/- 3 degrees)

Patient Care Benefits

• Allow more patients to have minimally invasive surgeries

• Smaller instruments enable smaller incisions– Less post-operative pain– Faster recovery– Shorter hospital stays– Less blood loss– Smaller scars

Current Applications

• First robot-assisted laparoscopy in 1997• Type and number of robot-assisted surgeries being

performed steadily increasing• Most studies show feasibility at the cost of increased

operating time• FDA clearance for:

– General Laparoscopy– GERD disease surgery (fundoplication)– Gastric Bypass– Heart valve repair– Prostate removal

Current Systems

• Da Vinci and ZEUS systems FDA approved for surgery

• Sung and Gill, 2001 compared 2 systems– Da Vinci had shorter operating times and learning

curve– Concluded both were effective

• Currently over 210 Da Vinci systems worldwide (USA, Canada, Japan, Europe, Australia)– 61 purchased last year – 70% in USA

Da Vinci Surgical System• Intuitive Surgical Inc., Sunnyvale CA• Robotic Cart with 3 or 4 robotic arms

– 198 x 94 x 97 cm, 544 kg

• Surgeon manipulates arms using joystick- like handles on control console

– 166 x 97 x 158 cm, 227 kg

Da Vinci Components

Master Controller

Robot Cart

Control Console

More Da Vinci System Features

• Kinematic (joint movement structure)– Surgeon uses open surgical movements and

techniques

• 7 degrees of Freedom (instruments have an articulating tip)

• Natural Stereoscopic vision– 2 channel endoscope, each channel sampled with

its own 3 chip NTSC camera and then displayed on own CRT display

– Surgeon immersed in endoscope view• Intuitive hand-eye coordination and superior depth

perception

ZEUS Surgical Robotic System

• ComputerMotion Inc, Goleta, CA (merged with Intuitive, 2003)

ZEUS System Features

• Over 40 instruments with articulating tips• Surgeons hand movements resemble traditional

laparoscopic movements• Robotic arms mounted on OR table rails

– Can adjust table w/o moving robot arms– Arms are compact and weigh < 40 lbs

• Voice recognition technology • Stereovision

– One large shutter glass fixed to TV screen polarizes two pictures on the screen to a polarized picture for each eye

System Set-up

Set-up of System for Surgery

• Console connected to robotic cart• Self-test (verify links and robotic arm function)• Robotic arms wrapped in disposable nylon covers

– Tips of arms contain microchips that connect surgical instruments

• Mechanical supports for trocars on the robotic arms fixed

• Frontal or inclined position of scope (0°-30°)• 2D or 3D vision selected• Image centered on the monitor after scope insertion• White balancing of robotic camera

More set-up…• Laparoscopic ports are

positioned and robotic cart or arms are installed

• Patient placed in surgical position

• Robotic arms are connected to optic and operating ports– Accurate placement of ports

and robotic cart necessary to avoid collisions between mechanical arms

Surgery Robotics Issues• Set-up of system is time-consuming

– Increased operating time– Time = $

• Overall costs are high– Basic system is over $1 million USD– Maintenance and upgrade costs– Training costs– Each instrument ~$1800

• Can only be used for 10 procedures

• Shortage of instruments• Cumbersome equipment

– Big, bulky cart set-up• Disconnection of instruments from robot (rare)

In Development…

• Smaller systems mounted on OR ceiling– Speed up OR set-up time

• More variety of instruments • Re-usable Instruments (> 10 uses)• Tele-surgery• Expansion of FDA approved procedures

– Clinical trial underway to determine appropriate robotic pressure for liver retraction

Conclusion

• The world of surgery is rapidly changing• The current generation of robotic systems

for laparoscopy have limitations but are an impressive beginning for a new era in surgery

• As surgeons and engineers continue to work together, future systems will likely evolve into tools that are beyond our current imagination

References• Intuitive Surgical Inc. Da Vinci website:

http://www.intuitivesurgical.com/products/da_vinci.html• ComputerMotion Inc. ZEUS website:

http://www.computermotion.com/clinicalapplications/roboticprocedures/generalsurgery/• Purkayastha S, Athanasiou T, Casula R, Darzi A. Robotic surgery: a review. Hosp Med.

2004 Mar;65(3):153-9. • Menkis AH, Kodera K, Kiaii B, Swinamer SA, Rayman R, Boyd WD. Robotic Surgery, the

First 100 Cases: Where Do We Go from Here? Heart Surg Forum. 2004 Jan 01;7(1):1-4. • Gerhardus D. Robot-assisted surgery: the future is here. J Healthc Manag. 2003 Jul-

Aug;48(4):242-51. • Ashton RC Jr, Connery CP, Swistel DG, DeRose JJ Jr. Robot-assisted lobectomy. J

Thorac Cardiovasc Surg. 2003 Jul;126(1):292-3. • Giulianotti PC, Coratti A, Angelini M, Sbrana F, Cecconi S, Balestracci T, Caravaglios G.

Robotics in general surgery: personal experience in a large community hospital. Arch Surg. 2003 Jul;138(7):777-84.

• Wykypiel H, Wetscher GJ, Klaus A, Schmid T, Gadenstaetter M, Bodner J, Bodner E. Robot-assisted laparoscopic partial posterior fundoplication with the DaVinci system: initial experiences and technical aspects. Langenbecks Arch Surg. 2003 Feb;387(11-12):411-6.

• Ruurda JP, van Vroonhoven TJ, Broeders IA. Robot-assisted surgical systems: a new era in laparoscopic surgery. Ann R Coll Surg Engl. 2002 Jul;84(4):223-6.