Robotic Laparoscopic Surgery
By Raymond Lance, MD, Urologic Oncology
 Robotic laparoscopic surgery is no longer the stuff of science fiction, but rather the latest technology to migrate from the bench to the bedside in our never ending quest to create minimally invasive alternatives to standard open surgical techniques. The daVinci robot by Intuitive SurgicalTM is FDA approved for a variety of surgical procedures.
Robotic surgical techniques:
· Mitral Valve Repair
· Epicardial Pacemaker Leads for BiVentricular Resynchronization
· Nissen Fundoplication
· Gastric bypass surgery
· Radical Prostatectomy (Da Vinci® Prostatectomy)
· Esophageal surgery
· Thymectomy for Myasthenia gravis
The daVinci system includes robotic arms (3 or 4 depending upon the configuration chosen), and a surgical console which allows the surgeon full control of the robotic arms and camera with instruments that employ a unique "endowrist" technology providing the surgeon 7 degrees of freedom. This allows the surgeon to operate the robotic instruments in the same way as his/her own hands but without tremor and with up to 11x magnification. Additionally, the 3-D visualization provides depth of field absent from traditional laparoscopic surgery.
The daVinci system is not the first robotic system. The Aesop robot was the first used in human surgery offering only control of the laparoscope via voice commands. Aesop was cumbersome and therefore sparingly used in most laparoscopic centers. The Zeus system offered more extensive laparoscopic control but similarly failed to gain widespread acceptance.
The daVinci robotic system was the end result of a Department of Defense (DOD) research effort to created telesurgical capability. The system was refined by a civilian companies in a collaboration culminating in Intuitive Surgical's current program.
 Case Study: Laparoscopic Radical Prostatectomy
It is estimated that there will be 232,090 new prostate cancers diagnosed in 2005 with an estimated 30,350 deaths of the disease. This represents the number one cause of cancer in men over 50 years and number 3 cause of cancer death. Radical prostatectomy has become the gold-standard for treatment of localized prostate cancer. The trend in recent years is increasingly directed toward minimally invasive treatment such as brachytherapy, cryosurgery and laparoscopic surgery.
French urologists Vallancien and Guillonneau first reported transperitoneal laparoscopic radical prostatectomy in 1998. Following their pioneering work, a flood of international studies confirmed the oncological equivalence of laparoscopic radical prostatectomy while demonstrating markedly lower blood loss, decreased urinary catheter dwell times, and more rapid return to full activity. Nevertheless, the greatest obstacle to widespread acceptance was the steep learning curve on the order of 50-100 cases and long surgical times. The key elements of laparoscopic radical prostatectomy explaining the long learning curve are the neurovascular bundle dissection to preserve erectile dysfunction and the urethral-bladder anastamosis.
The daVinci robotic system for radical prostatectomy was first used and reported in 2001 by Abbou. Published reports of large patient numbers by Menon and Ahlering have demonstrated a much shorter learning curve of only 5-10 cases with remarkably good margin positive rates of 9-15% comparable to the best open surgical series. The major improvement provided by the robotic system in superior dissection with astounding visualization and ease of suturing especially in the tight confines of the pelvis.
 The daVinci system has been deployed in more than 300 hospitals world-wide since 2001 with more than 3000 radical prostatectomies performed nationwide.
The future of Robotic Surgery
The success of daVinci radical prostatectomy along with the robotic cardiothoracic procedures have opened up avenues to expand laparoscopic surgical treatment where only open surgery has been used. The daVinci technology will only get better and smaller. With recent release of 5 mm instruments over the usual 8 mm instrumentation, robotic laparoscopic pediatric surgery will increasing be feasible.
For more information on Robotics, call Providence's Physicians Practice line at (907) 743-2348.
Published, July/August 2005, Physicians Practice
|
