Robotic Surgery: Precision and Care

Robotic surgery is a type of minimally invasive surgery that uses robotic systems to assist surgeons in performing complex procedures with greater precision, flexibility, and control than is possible with conventional techniques. 

Dr. Govind NandaKumar– Visual Representation of Robotic-Assisted Surgery

Key Advancements and Milestones

The PUMA 200 (Programmable Universal Manipulation Arm) robotic system was used to perform the first documented robotic surgery in 1985. A neurosurgical biopsy was performed using the robot, which positioned a needle for a brain biopsy, marking the beginning of robotic assistance in surgery.

In 1988, researchers achieved another significant milestone by using the PROBOT, which stands for “Prostate Robot,” for transurethral resection of the prostate, a procedure that treats benign prostatic hyperplasia (BPH), the enlargement of the prostate gland. The first FDA approved robotic surgery was the da “Vinci Surgical System” in 2000, that popularised and brought it into widespread use for various complex procedures.

How Robotic Surgery Works: A Step-by-Step Guide

Robotic surgery, also known as robot-assisted surgery, involves using robotic systems to perform surgical procedures. These systems provide enhanced precision of the surgery than manual method, compliance and control, enabling surgeons to perform complex surgeries with greater accuracy, reducing the risk of complications and improving outcomes.

 Here’s a general overview of how surgeons conduct a robotic surgery procedure:

Preoperative Preparation

  • Patient Evaluation: The patient undergoes a thorough evaluation, including medical history, imaging studies (like CT scans or MRIs), and lab tests to assess suitability for robotic surgery.
  • Preoperative Planning: Surgeons use advanced imaging and planning software to create a detailed surgical plan. In orthopaedic procedures, for example, they might create a 3D model of the joint to be replaced.

Patient Positioning

The surgeon places the patient on the performing table, taking care to ensure the best fit of the robotic arms to the surgical site. Under general anesthesia, the patient is anesthetized.

Setting Up the Robotic System

  • Trocar Placement: Small incisions are made for the insertion of trocars (thin tubes through which surgical instruments and the camera will pass). The surgeon guides these into place.
  • Docking the Robot: The robotic arms dock to the trocars. Each arm holds an instrument, such as a scalpel, scissors, or a camera, controlled by the surgeon.

Surgical Procedure

  • Surgeon Cabinet: The surgeon sits at a cabinet, away from the patient, controlling the robotic arms. The cabinet provides a enhanced, high-definition 3D view of the surgical area.
  • Robot-Assisted Surgery: The surgeon manipulates the instruments using the cabinet’s hand controls. The robotic arms translate the surgeon’s movements into precise actions inside the patient’s body, often with more proficiency and range of motion than the human hand.
  • Real-Time Feedback: The system provides real-time feedback, helping the surgeon avoid damage to surrounding tissues and ensure precise movements.

Completion of Surgery

The robotic arms are detached and the instruments are carefully removed once the procedure is completed. The small incisions are then closed, using sutures, staples, or adhesive strips.

Postoperative Care

After the surgery, the medical team moves the patient to a recovery room and monitors them as they wake up from anesthesia. Depending on the procedure, the recovery time may be shorter, with less postoperative pain and a quicker return to normal activities compared to traditional open surgery.

Follow-Up

The patient’s recovery, pain, and potential complications are to be monitored, managed, and addressed during follow-up visits.

Robotic-Assisted Surgery
Krupamayi Hospitals– Surgeon operating the surgery from cabinet

Advantages of Robotic Surgery

Enhanced Precision: The robotic system allows for more precise movements, reducing the risk of errors.

Minimally Invasive: Smaller incisions lead to reduced blood loss, minimal scarring, and shorter recovery times.

Improved Visualisation: The high-definition 3D camera provides better visibility of the surgical area.

Reduced Surgeon Fatigue: The ergonomic design of the cabinet reduces physical strain on the surgeon during long procedures.

Robotic Surgical Technology: Advanced Features

Several types of robots are used in surgeries for specific tasks or types of procedures. Here’s an overview of some of the key robotic systems used in surgery:

Da Vinci Surgical System

The Da Vinci Surgical System is a robotic platform designed to enhance the precision and control of surgeons performing minimally invasive surgeries. Developed by Intuitive Surgical. In various medical fields, including urology, gynaecology, cardiothoracic surgery, and general surgery, it is commonly used.

Key Features:

  • Surgeons handles the procedure sitting in cabinet with enhanced 3D visualisation, precision, and control through its robotic arms that mimic the surgeon’s hand movements
3D visualization on screen of performing sugery by robotic arm
3D visualisaton on screen during real time surgery

Rosa Robot

The Rosa robotic system, developed by Zimmer Biomet, is a robotic-assisted platform designed for use in orthopaedic and neurosurgical procedures. It enhances the precision and efficiency of surgeries, particularly in spinal and brain surgeries. Here’s a detailed overview of the Rosa robot:

Key Features:

  • Spinal and brain surgeries, such as spinal fusion, epilepsy, parkinson’s disease, tumors, and other complex procedures, are performed using the Rosa Robot, which is specifically designed for this purpose.
  • It aids in preoperative planning and intraoperative real-time navigation and guidance to surgeons
  • The system uses modern imaging technology to create detailed 3D models to provide updated anatomical information during the procedure.
  •  It also assists in the placement of screws and other hardware with high precision helping surgeons plan and execute precise interventions.

CyberKnife

CyberKnife is a type of non-invasive robotic stereotactic radiosurgery system made by Accuray. This machine treats a variety of conditions, delivering precise, high-dose radiation therapy to brain tumors, spinal tumors, and abnormal growths in the lungs, liver, and pancreas.Unlike traditional radiation therapy, which may involve multiple sessions over several weeks, CyberKnife typically provides a single high-dose treatment or a few sessions.

Key Features:

  • The system uses a robotic arm to deliver radiation from various angles, allowing for precise targeting of tumours while minimising damage to surrounding healthy tissue.
  • CyberKnife incorporates real-time imaging technologies to track the tumour’s position and adjust the treatment delivery accordingly with high doses of radiation in a few sessions. 
  • This is especially useful for tumours that may move due to patient breathing or other factors.

Versius Surgical System

The Versius Surgical System, developed by CMR Surgical, is a robotic-assisted surgical platform designed to enhance minimally invasive surgeries. It aims to improve the precision, flexibility, and control of surgical procedures, similar to other robotic systems like the Da Vinci but with some distinct features.

Key Features:

  • Surgeons operate from a cabinet that provides a high-definition, 3D view of the surgical field. 
  • The cabinet controls offer a fine motor, controlling the lightweight robotic arms that allows precise movements and better management of the surgical procedure. 
  • Robotic arms can be equipped with surgical instruments, expanding the capabilities for performing a diverse range of procedures in various surgical specialties.

ExcelsiusGPS

ExcelsiusGPS is a robotic-assisted navigation system developed by Globus Medical, designed to enhance precision and efficiency in spinal surgery. The system combines robotic assistance with advanced navigation technology to improve the accuracy in the field of orthopaedic and neurosurgical procedures.

Key Features:

  • The surgeon handles the robotic arm from the cabinet and assists in the precise placement of screws, rods, and other spinal hardware. It helps in reducing deviations and improving accuracy compared to traditional techniques. 
  • ExcelsiusGPS integrates with imaging technologies like fluoroscopy and CT to provide real-time feedback and navigation during the complex spinal anatomy and positioning and alignment of implants, allowing for adjustments during the procedure to ensure accuracy.
  • Surgeons use preoperative imaging to create a 3D model of the spine. This model helps in planning the procedure and positioning the robotic system for optimal results.

Senhance Surgical System

The Senhance Surgical System, a robotic-assisted surgical platform, is developed by Asensus Surgical (formerly TransEnterix). The system integrates several advanced technologies to support surgeons during various types of procedures. In various surgical specialties, including general surgery, gynaecology, and urology, surgeons use the Senhance Surgical System.

Key Features:

  • The Senhance system features robotic arms that can hold and precisely operate various surgical instruments. These arms offer enhanced proficiency and precision compared to traditional laparoscopic tools. 
  • The system provides haptic feedback, giving surgeons a sense of touch and resistance during the procedure. This helps in fine-tuning movements and improving precision. 
  • A 3D high-definition camera placed with a surgical instrument provides a detailed, magnified view of the surgical field in the system. This improves visualisation of the anatomy and surgical site.
  •  Surgeons use a touchscreen interface to control the robotic arms and camera, allowing for intuitive adjustments and streamlined operation.

Navio Surgical System

Smith+Nephew developed the Navio Surgical System, a robotic-assisted platform designed to enhance precision and efficiency in orthopaedic surgeries, particularly for knee procedures, including partial and total knee replacements. It integrates advanced imaging and navigation technologies to support surgeons in performing complex joint surgeries with improved accuracy.

Key Features:

  • During knee surgeries, the Navio system assists in precise bone preparation and implant placement for specific tasks such as bone cutting and shaping. The surgeon ensures proper placement of surgical components by accurately aligning them with the patient’s anatomy.
  • The system uses real-time imaging to create a 3D model of the knee. This model guides the robotic arm and supports accurate positioning of implants.
  • Surgeons interact with the system through a touchscreen interface, allowing for easy adjustment of surgical parameters and real-time monitoring.

Magellan Robotic System

Hansen Medical developed the Magellan robotic-assisted surgical system for catheter-based procedures. Medical professionals use it in various applications, including electrophysiology, vascular interventions, and other minimally invasive procedures that require precise catheter manipulation.

Key Features:

  • In the Magellan system, the surgeon performs surgery from the cabinet with a robotic arm that controls the catheter with high precision. This allows for accurate navigation and manipulation within the vascular system or other anatomical structures.
  • The system integrates with imaging technologies, such as fluoroscopy, to provide real-time visualisation of the catheter and its position within the body. This helps guide the procedure and ensures accurate placement.

Monarch Platform

Auris Health, part of Johnson & Johnson, developed the Monarch Platform, a robotic-assisted surgical system designed for minimally invasive procedures. Surgeons primarily use it for diagnostic and therapeutic procedures in the lung, including biopsies and treatment of lung cancer, but its technology can assist in various other procedures that require precise navigation and manipulation.

Key Features:

  • The surgeon operates from a cabinet using flexible endoscopic tools that a robotic arm controls, providing precise control and movability for navigating through the bronchial tree and other hard-to-reach complex anatomical structures.
  • The system integrates with advanced imaging technologies to provide high-definition, 3D views of the anatomical area, improving visualisation and guidance during procedures.

Mako Robotic-Arm Assisted Surgery System

The Stryker Corporation developed the Mako System for use in orthopaedic surgeries, such as joint replacements, including total hip, total knee, and partial knee replacements.

Key Feature:

  • Surgeons allow for detailed preoperative planning using CT-based 3D modelling to create surgical plans tailored to the patient’s anatomy. 
  • During Surgery, the robotic arm guides the surgeon within predefined areas, providing real-time visual, tactile, and auditory feedback. This allows for precise bone preparation and implant placement, enhancing accuracy and potentially improving patient outcomes.

Hugo RAS System

The Hugo™ Robotic-Assisted Surgery (RAS) System is a modular platform developed by Medtronic for minimally invasive surgery. General surgeries like cholecystectomy, hernia repair, and bariatric surgery are performed using the technique. It is also applicable in Urology, Gynecology, Thoracic and Colorectal surgery.

Key Features:

  • The surgeon makes small incisions and inserts trocars (small tubes) as entry points for the robotic instruments.
  • The trocars dock the Hugo robotic arms, with each arm controlling a different instrument, such as a camera or surgical tool.
  • The surgeon sits at a cabinet, where they view the surgical site in high-definition 3D and control the robotic arms with precise movements. 
  • The system translates the surgeon’s hand movements into more precise micro-movements of the instruments. When the procedure is completed, surgeons undock the robotic arms, remove the instruments, and close the incisions.

CorPath GRX system

The CorPath GRX System is a robotic-assisted platform developed by Corindus, a subsidiary of Siemens Healthineers, designed specifically for percutaneous coronary interventions (PCI), such as angioplasty and stenting, as well as other vascular procedures.

Key Features:

  • Doctors use the CorPath GRX system to perform PCI, a procedure in which they insert a catheter through the blood vessels to open up blocked or narrowed coronary arteries, typically involving the placement of a tube.
  • The system allows the interventional cardiologist to control guidewires, catheters, and stents with robotic precision from a cabinet outside the radiation field, reducing the risk of radiation exposure to both the physician and the patient

REVO-i

The Revo-i robotic surgery system is a robotic-assisted surgical platform developed by the South Korean company Meere Company. It is used in General Surgery, Urology, Gynaecology, Thoracic and Colorectal Surgery.

Key Features:

  • The Revo-i system for surgical procedures features multiple robotic arms, each equipped with surgical instruments such as scissors, graspers, and energy devices.
  • The system provides surgeons with a 3D high-definition view of the surgical field. The Revo-i includes an ergonomic cabinet where the surgeon sits and controls the robotic arms using hand controllers. 
  • One of the primary aims of the Revo-i system is to provide a more inexpensive option for robotic surgery.

PRECEYES

A highly specialised robotic platform is designed for ophthalmic surgery, focusing particularly on procedures within the eye. It was developed by PRECEYES B.V., a spin-off from the Eindhoven University of Technology.

Key Features:

  • Surgeons use the PRECEYES system for performing highly delicate and precise eye surgeries, such as retinal and vitreoretinal procedures.
  •  One of its key applications is in delivering subretinal injections, where the system can precisely inject therapeutic agents directly beneath the retina. 
  • This is particularly relevant for treating conditions like age-related macular degeneration (AMD) and other retinal disorders.

Ottava System

Johnson & Johnson’s Ethicon subsidiary developed the next-generation robotic surgery system named Ottava. It is still under development and aims to compete with other robotic systems like the Hugo RAS and the da Vinci Surgical System.

Key Features:

  • Ottava will offer advanced features with greater flexibility in operating room setups, improved instrumentation, and enhanced imaging capabilities, aiming to make robotic surgery more accessible and efficient. 
  • However, since it is still in development, its specific applications and availability might evolve as the platform progresses.  
  • It will be applicable in General Surgery, Urology, Gynaecology, Thoracic and Colorectal Surgery.

Mazor and stealth Edition

The Mazor X Stealth Edition is a result of combining Medtronic’s StealthStation technology with Mazor Robotics’ spine surgery platform. 

Key Features:

  • This combining technology provides real-time image guidance and surgical planning tools.
  • Spinal surgeries such as spinal fusions, vertebral body tethering, and scoliosis corrections primarily use it.
  • The system assists surgeons in planning the surgery, accurately positioning implants, and navigating complex spinal anatomy.

Each type of robotic surgery offers benefits like smaller incisions, reduced blood loss, shorter recovery times, and increased precision. However, they also require specialised training and can be more expensive than traditional surgical methods.

Surgeons use these robotic systems to enhance the efficacy of their procedures, increasing precision, safety, and effectiveness. They are the next revolution in Surgical Intervention.

Reference

https://academic.oup.com/bjs/article/102/2/e15/6141447

https://jamanetwork.com/journals/jama/article-abstract/193511

https://ieeexplore.ieee.org/abstract/document/195948

https://link.springer.com/article/10.1007/PL00007078

Wriiten by Rutuja Adake

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