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Robotic-assisted
surgery: Recent advances and potential cost savings
 Technology
has long been a central component of medicine and surgical
intervention. Sophisticated monitors, for example, are used
to monitor the anaesthetized patient, and automated blood
pressure cuffs continuously watch for fluctuations. Technology
is even routinely used as a temporary surrogate for human
organs - the dialysis machine assists weakened kidneys in
their function and the bypass machine mimics the human heart
in circulating blood throughout the body during coronary artery
bypass surgery. And now, recent advances in robotic-assisted
surgery are revolutionizing contemporary medicine by increasingly
bringing technology into a more human role. Robots are now
being used as an intermediary between the expertise of the
surgeon and the body of the patient.
Robots provide a steady and predicable interface with the
patient that may be scaled down in size, allowing for smaller
incisions and shorter lengths of stay. Proponents of robotics
suggest that, in time, these technologies will leverage the
advantages of the human mind (the surgical and anatomical
knowledge of the physician), and technologically correct the
deficiencies of the human hand by miniaturizing its function
in the form of robots that are more capable of making small,
precise movements. The result will be less invasive surgery,
less trauma to tissues, quicker recovery times and more cost-effective
surgical interventions.
Robotic-assisted surgical technology: A brief history
One
of the pioneering efforts in the development of robotic-assisted
surgery has been a joint collaboration in the United States
between the National Aeronautics and Space Administration
(NASA), the Jet Propulsion Laboratory and private interest,
MicroDexterity Systems. As part of the Jet Propulsion Laboratory’s
Telerobotics Program, these interests formed the Robot Assisted
MicroSurgery (RAMS) project in the early 1990s. The purpose
of this program was to build the technology and workstations
necessary to improve robotic dexterity, enabling microsurgical
procedures to advance to the point where they could be applied
to procedures of the eyes, ear, nose, throat, face, hand and
brain.
RAMS is designed to permit telemanipulation of the robotic
devices, and has a ‘share’ function in which surgeons
can interactively operate the robot with other surgeons participating
in the intervention. Other advances of RAMS include features
that may improve patients’ clinical outcomes who are
treated by less experienced surgeons. This is accomplished
by RAMS features that improve surgeons’ positioning and
movements that are susceptible to myoclonic tremor. This unsteadiness
of the human hand prevents some surgeons from accurately practising
fine-motor manoeuvers during an operation.
By 1994, the RAMS project had successfully developed a robotic
arm measuring 2.5 cm in diameter and 25 cm in length that
was capable of six degrees of motion. The following year a
system of kinematics and high-level control was added that
included an electronic safety system. This technology was
successfully tested at the Cleveland Clinic Foundation in
the late 1990s during a simulated eye microsurgery. Subsequent
work produced a dual-arm telerobotic microsurgery workstation
that was capable of microsurgical suturing.
Another group in the United States independently produced
a robotic surgical device, the da Vinci Surgical System, and
received Food and Drug Administration (FDA) approval for it
last July. Initially approved for use in five US hospitals,
the da Vinci is operated by a surgeon who sits at a computer
terminal and uses joysticks to manoeuver the device. Separately,
cameras are inserted into the patient’s body to give
a three-dimensional view of the body interior. Prior to using
the da Vinci on humans, surgeons are trained on live pigs
and human cadavers. Thus far it has been used with success
in procedures such as gall bladder removal, and does appear
to lead to shoter post-operative lengths of stay. Other successful
international research groups have also produced robotic-assisted
microsurgical devices and by the end of the 1990s application
of the technology was being applied in several clinical domains,
most notably, in cardiovascular surgery, hip replacement,
and brain surgery.
Robotic-assisted heart surgery
The
first coronary artery bypass surgery using a robotic device
was performed in Germany in 1998 using a system called ‘Intuitive.’
During the procedure, rather than splitting the sternum and
opening the chest cavity as is usually done during bypass
surgery, the surgeons made only small incisions less than
one centimeter wide. Intuitive’s three robotic arms were
placed through these incisions, one holding a camera and the
other two holding surgical instruments. During the operation
the surgeon had a full image of the heart’s anatomy on
a television monitor and was able to successfully complete
the bypass.
This protocol of robotic heart surgery, characterized by small
incisions and the use of cameras and robotic arms, is now
being applied to more areas of cardiovascular surgery. It
is now becoming more common for heart valve replacements to
be performed with robotic assistance and the early results
are noteworthy. Because the procedures are less invasive,
patients are less likely to have bleeding complications and
hospitals and health plans less likely to bear the financial
burden of these complications. Patients report less post-operative
pain and hospital lengths of stay have also been reduced.
Although the cost of these robotic devices must be considered
when computing the cost reductions they can bring, like most
technology, it is expected that the costs of robotics will
decrease as the FDA approves more devices and competition
in the robotics industry increases.
Robotic-assisted hip replacement
As
the population ages, hip replacement surgery is becoming more
common; hundreds of thousands of replacements are performed
each year. Robotics is providing surgeons with a new tool
in both surgical planning and assisting during the actual
surgical procedure.
In the planning phase of hip replacement surgery, X-ray computed
tomography is used to produce an image of the patient’s
femur. This allows the physician to use the three-dimensional
image of the femur shape to select the appropriate hip replacement
joint from a catalogue. This spatial information of the patient’s
unique femur shape is then provided to the robot so that the
initial robotic drilling is placed precisely where it is needed.
Historically, one out of every three hip joint replacements
fails within ten years. This drives up medical costs and significantly
reduces patients’ functional status and quality of life,
as they must endure another invasive procedure at a later
stage. Initial results indicate that hip replacement procedures
using robotic assistance have a higher rate of success relative
to the traditional method of hand-friased intervention. Thus,
robotics appears to be improving quality of care and reducing
repeat procedures within this clinical domain. Developers
are currently expanding orthopedic applications to kneecap
replacement and knee ligament repair.
Robotic-assisted brain surgery
At
the Ames Research Center in Mountain View, California, NASA
scientists are developing a robotic device that will have
the capability to learn the characteristics of the human brain
using neural net software. The robot, with a small probe,
has the ability to enter the skull and feel the surface of
the brain structure using a pressure sensor. Because brain
tumors have different densities than normal brain tissue,
the robot is designed to assist surgeons in locating cancerous
areas and tumor boundaries. The learning capability of the
probe also allows for it to distinguish between brain and
arterial tissue. Thus, when it reaches the surface of an artery
it will stop before penetrating the vessel and causing a bleed,
a common complication of brain surgery.
Drawing upon other advantages of robotics, the Ames Research
Center robot is a fraction of the size of the probes normally
used during brain surgery (0.2in in diameter). This reduces
the risk of brain injury and surgical complications that can
leave patients debilitated and drive up medical expenses.
This technology also has the capability of using the probe
to detect differences in temperature, acidity and presence
of chemicals, making its successful application in other clinical
domains likely.
The future of robotic-assisted surgery
As
the cost of robotics decreases and production and competition
increase, the use of robotic-assisted surgeries will grow.
This has the potential to decrease surgical complication rates
and the hospital costs associated with them. Patients undergoing
the less invasive robotic-assisted surgeries are likely to
experience less pain and, therefore, to report higher satisfaction
with their treatment, the hospital treating them and their
health plan.
Robotics also has the potential of expanding specialized surgical
care to areas of the world where there are few specialists
with the appropriate surgical training. In early telemedicine
experiments using robotics, surgeons have successfully performed
operations from miles away using a closed-circuit television
to operate the robot and communicate with on-site, ancillary
surgical staff. This could expand the reach of medical advances
and improve the health and quality of life of a broader population
than that currently reached.
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