The console looks like something that might control a submarine’s periscope, or a top of the range video game. There’s a padded seat positioned in front of what resembles an Oculus Rift VR headpiece. Several foot pedals are within easy reach. The joysticks have thumb and forefinger grips. To start the machine, all you need to do is push your forehead against a pressure pad comfortably positioned just above the eyepiece.
But this isn’t a toy. The device can – literally – be the difference between life and death. The controls of the da Vinci machine remotely operate a variety of surgical instruments, and cameras and robotic arms in another part of the room. In a training session, observers watch the scene – a rubberised version of human viscera – in 3D.
The joysticks manipulate a pair of metal pincers. It takes no more than a minute’s practice to learn to position rubber bands onto variously coloured rubber towers and then another minute to learn to tie the rubber rings together. The pincers’ range of movement and responsiveness is uncanny.
Moving from the console to the robot on the other side of the room, you discover that the rubber anatomical model that’s being practised on is miniscule. Everything’s been magnified tenfold. The big rubber rings the robotic pincers have been manipulating are smaller than the diameter of a pencil. And suddenly, it becomes easy to see why robotic systems like da Vinci represent the future of surgery.
No robosurgeon just yet
Strictly speaking, robotic surgery is actually robot-assisted surgery. The surgeon remains in full control, with the robot just an alternative means of getting the requisite surgical tools into frequently narrow or difficult to reach corners of the body. True robotic surgery – where a robot acts autonomously – doesn’t exist yet, though Professor Philippe Morel, head of visceral surgery at the Geneva University Hospitals says it is coming. Even so, these robotic systems are revolutionary, helping surgeons produce better outcomes for patients.
“For 4,000 years surgery was broadly unchanged. The tools in use then are still recognisable as the tools we use now,” Prof. Morel says. Until laparoscopic, or keyhole, surgery was developed during the 1980s, the major surgical innovations of recent millennia centered around pain relief and infection prevention.
Robotic systems are revolutionary, helping surgeons produce better outcomes for patients
What’s more, keyhole surgery itself was, in some respects, a step backwards, Prof. Morel says. Although it offers benefits for the patient like minimal scarring – keyhole surgery is performed through one or more small incisions – and less blood loss and shorter recovery times than open surgery, it can be difficult to perform.
For one thing the field of vision offered by standard laparoscopic cameras is considerably narrower than what surgeons can see when they open a patient up. And the long stemmed surgical tools they use are unwieldy, with seriously restricted range of movements. “It’s like performing surgery with sticks,” Prof. Morel explains.
Early efforts at surgery using robotic arms were made during the 1990s. Some systems were badly designed, including one whose operating tools moved in the opposite direction to the surgeon’s hands. But as systems were refined, their advantages over both keyhole and traditional open surgery became apparent. For instance, the da Vinci system not only offers surgeons stereoscopic vision through two laparoscopic cameras, but the tiny surgical instruments on its four arms have more flexibility and range than the human hand.
Experience from both sides of the roboknife
Prof. Morel’s advocacy for robotic surgery stems from his experience on both ends of the surgeon’s knife. In 2009, his prostate was removed by surgeons using a robotic system. The result, he says, was a faster recovery, with fewer days in hospital and less discomfort.
As a surgeon specialising in abdominal surgery, he appreciates the flexibility robotic surgery gives him in confined spaces like deep within the pelvis. Little wonder then that robotic surgery has been enthusiastically adopted for gynaecological procedures and those involving the urinary tract.
In all, there are nearly 4,000 da Vinci systems in use worldwide, with some two-thirds in the US. The number of robotic procedures undertaken has grown at around 15 per cent a year over the past two decades. Allied Market Research estimates that the market for robotic surgical systems will have doubled to USD6 billion by the end of the decade from 2014.¹ Demand is likely to rise as surgeons become more familiar with robotic systems and as fresh innovations are introduced. These include clusters of tiny snakelike robotic tools encased in narrow tubes that can be fed through a patient’s natural orifices to target points deep inside the body. Da Vinci has squeezed three tools plus a camera, each independently operated and with broad ranges of movement, into a tube with a diameter of just 12 millimetres.
Further enhancements include dual consoles allowing surgeons to operate simultaneously with organ specialists. Hitherto, they’ve had to alternate at the sole console during procedures.
The virtues of VR
Virtual reality (VR) systems are also being developed so that scans of patients’ organs can be superimposed over what the cameras can show. This would allow surgeons to see through tissue like fat that might be blocking their view of the underlying problem. What’s more, VR could allow surgeons to pre-plan dissections with greater precision, ensuring, say, that they remove the whole of a cancer while preserving as much of the healthy tissue as possible. The existing approach of erring on the side of caution often means making much bigger cuts than they’d ideally like.
“Augmented reality will help surgeon with proper navigation,” Prof. Morel says.
For this VR technology to be really effective, the projected image would have to be dynamic, adjusting with the organ as it moves and shifts under the surgeon’s knife. Eventually there could be sensors within the surgical tools: tissue can offer a lot of information on, say, temperature and oxygenation.
Such developments, Prof. Morel explains, would enable instruments to deliver information directly to the surgeon.
That is one of the current weaknesses of robotic surgery – the lack of haptic feedback, which is to say, from touch. A surgeon can’t feel the tissue’s resistance from his console seat. To suture through cartilage or bone, Prof. Morel has to leave the console and take direct command of the surgical tools. Ultimately, this haptic feedback will be built into the robotics – indeed, some new systems are already making strides in that direction.
Sensory deprivation
But until then, this sensory deficiency can be a problem. Many of the patient injuries associated with robotic surgery are caused when tools move outside of a surgeon’s field of vision and are subsequently moved. Without a sense of how much resistance there is to a move, surgeons can tear tissue or rip apart blood vessels. This can be costly in more ways than one. In the US there are 4,000 lawsuits alleging damage caused by robotic surgical systems.
But that’s not the robots’ fault.
“The most dangerous thing for the patient is the human element. The surgeon,” Prof. Morel says. “The patient is dependent on surgeon’s mood, how tired they are, whether they’re in a rush.”
This is as true regardless of whether surgeons are holding the knife directly in their hands or using a robot to operate with. Indeed, robots can make surgery safer. “Less dependence on human factors will make surgery much less risky,” he says.
Much has to do with proper surgical training. For instance, out of more than 2,000 robotic procedures undertaken at the Geneva University Hospital, there hasn’t been a single significant issue, Prof. Morel says. These days, surgeons are trained and certified to use robotic systems, with higher level training programmes being introduced for more complicated procedures.
One major drawback of robotic systems is cost. For instance, the system itself costs CHF1.5 million with an additional yearly maintenance charge of CHF100,000, while instruments cost CHF150 per use. But set against that must be fewer complications and shorter hospital stays. And as robotic systems become more prevalent, economies of scale and competition could well drive down expense as it has done in all corners of technology. In other words, the robotic surgeon is here to stay.
¹Allied Market Research, “Surgical Robotics Market by Component (Systems, Accessories, Services) and Surgery Type (Gynecology , Urology, Neurosurgery, Orthopedic, General) – Global Opportunity Analysis and Industry Forecast, 2014 – 2020”
