Robotic Laparoscopic Surgery

Da Vinci robot: Future of surgery

Robotic Laparoscopic Surgery | Johns Hopkins Medicine

The future of surgery is . . . Wall-E? Well, sort of.

The Da Vinci surgical robot currently making its home in the Mock Operating Room in the Computer Science and Engineering Building here at Homewood is pretty loveable, as far as robots go. But the Da Vinci robot is also much more than just a pretty motherboard or some fancy software.

The Da Vinci machine consists of a surgical section – which features not only mounts for various “wristed” implements a surgeon might use during a procedure, but also a high-definition “3D” camera that transmits the image (usually from inside a patient) to a console at which the surgeon sits. It is also at this console where the surgeon directs the robot's movements via two small sets of loops that fit around the fingers of the operator.

It was developed by the medical technology company Intuitive, and is now currently on loan at Hopkins. About a thousand other robots the Da Vinci are currently in use around the world.

With the Da Vinci and its cousin machines, scientists and surgeons hope to take advantage of the many benefits of surgical assistant bots: anatomical modeling, surgical planning, medical imaging and a greater range of motion for surgical instruments.

Currently, robots similar to Da Vinci are used for laparoscopic surgeries that involve making two small incisions in the patient, one into which a camera is inserted and the other into which the actual surgical instruments are placed. Currently, similar surgical robots are used in a variety of laparoscopic surgeries, including nephrectomies to remove cancerous kidney tumors, heart valve repair and some gynecological procedures.

However, much of the research at the Engineering Research Center for Computer Integrated Surgical Systems and Technology (ERC CISST), which is based at Hopkins, is also aimed at microscopic surgeries, which will overcome the physical limitations imposed on current surgical systems to better treat an even wider range of illnesses with even greater effectiveness and much higher precision.

In reality, the robot is actually just one more tool Hopkins' faculty and students are adding to their already extensive arsenals.

The mock OR was founded as a part of the Engineering Research Center, which got its start more than 10 years ago with the help of a grant from the National Science Foundation.

The University is the lead institution of the ERC, and collaborates with the Hopkins hospital and medical school, Carnegie Mellon and the Massachusetts Institute of Technology.

Located in the tunnel through the CSEB building between the Decker and Wyman Quads, the mock OR is a state-of-the-art recreation of a real-life operating room, a set-up that Hopkins researchers hope to use to more effectively study surgeons at work in order to facilitate the creation of better and more advanced software programming to run robots the Da Vinci surgical system.

That being said, the robot is not intended to be a replacement surgeon. The robot will not function unless an operator sits at the helm, peers into the eyepiece and manually maneuvers the robot's mechanical arms.

“The operating room is getting smarter,” Russell Taylor said, who is the director of the ERC CISST and one of the many Hopkins faculty members who work on and with the Da Vinci system.

However, surgeons don't have to be too worried about looking for other jobs in the near future.

Though no live-patient surgeries are done in the mock OR, researchers (which include faculty and graduate students as well as undergraduates) at the Homewood campus recruit colleagues from the medical school to help in their investigation of the Da Vinci system.

“We have close working relationships with end users in the medical school – surgeons – who work with us,” Taylor said. “The mock operating room is actually a systems integration laboratory in which the goal is to bring all of these components – imaging, robots and human interfacing – together to test it in a realistic environment.”

Thus, scientists Taylor can study how robots and humans come together in a surgical setting, which inevitably will help them to develop better software and fine-tune pre-existing surgical robotic systems for use in real operating rooms in the future. “We use plastic phantoms on which we can do much of the testing before doing live testing at the medical school,” Taylor said.

By analyzing how these surgeons interact with and utilize the system, researchers Taylor hope to develop computer-based systems to improve interventional methods, such as software that could enforce safety measures in case a surgeon gets a little too close to delicate tissue during a tricky procedure.

The greatest potential offered by the integration of surgical robots into more surgeries is their especially large capacities to integrate huge amounts of information. Theoretically, these robots can take database information (including anatomical atlases, etc.

), combine it with individualized patient info (such as medical imaging results) to allow the surgeon to better analyze individual surgeries, making them safer and more efficient, which in turn allows patients to experience less painful, faster, and more efficient procedures and recoveries.

The research done within the CISST ERC framework is widely varied, but most focuses on enhancing the current technological surgeries; Taylor, for example, has lent his mind power to several different problems in the last several decades; he has worked not only here at Hopkins, but also at IBM, developing a surgical robotic system in the early nineties called Robodoc, which was used to increase the precision of hip implant surgeries.

And not only has he worked to advance surgical robotics, but he has also moved into the realm of mentorship of young undergraduate minds. Taylor teaches several classes on campus that apply to medical robotics, including those on computer-integrated surgery and medical imaging. “Our focus is on both research and education,” he said.


Robotic Surgery Risks and Benefits – Is a Robot Right for You

Robotic Laparoscopic Surgery | Johns Hopkins Medicine

2013 Intuitive Surgical, Inc

Surgeons demonstrate the da Vinci Si robot.

En español l In 2010, Paul Elliott, then 55, a high school teacher at a public school in Gonzales, California, checked into a hospital to have his prostate removed.

When he awoke, he had no feeling in his shoulders and arms. During the eight-hour operation, his body had been suspended in a steep head-down position to accommodate the positioning of the robot used to assist the surgeon. Elliott suffered nerve damage and never regained full use of his left hand.

Elliott is one of more than a million people in the U.S. who have undergone robotic surgery since it was introduced in the 1990s. He is also one of a growing number of casualties.

While robotic surgery dates to 1992, when a 64-year-old man had his hip successfully replaced with the assistance of a machine called Robodoc, it wasn't until the U.S. Food and Drug Administration (FDA) cleared the da Vinci robotic system in 2000 for a large swath of minimally invasive procedures that the concept took off.

Over the past decade, some 2,000 surgical robots have been sold in the U.S., and the number of robotic procedures, for everything from delicate head and neck surgery to routine hysterectomies, has soared by 30 percent each year. Experts attribute the surge to aggressive marketing that plays up the robot's wow factor.

“Billboards and TV commercials can make hospitals that have the robot seem more high tech and cutting edge,” says Karen Schoelles, M.D., medical director of the ECRI Institute, a nonprofit research organization that assesses safety and cost-effectiveness in patient care.

But robots in the OR may not be living up to their promise. “Years of data tell us that for many procedures, there's no benefit to the patient over standard minimally invasive surgeries,” says Marty Makary, M.D.

, a surgeon at Johns Hopkins Hospital in Baltimore and author of several studies on robotic surgery.

“While the robot provides a benefit in some operations, most uses are for procedures where there are no advantages and there may be potential risks.”

Hysterectomy, the second-most-common surgery for American women, is a good example. According to a recent Journal of the American Medical Association study of more than 250,000 procedures, hysterectomies performed with the da Vinci robot had no better outcomes than those done through laparoscopic surgeries.

“All of the studies so far show it's no better or worse, but it takes longer and is more expensive,” says James T. Breeden, M.D., immediate past president of the American Congress of Obstetricians and Gynecologists.

Reviews of studies on other operations, including gallbladder removal, colorectal surgery and procedures to reverse reflux, have reached similar conclusions.

The FDA originally cleared the use of surgical robots for general laparoscopic surgery — minimally invasive procedures done through small incisions — which reduces the risk of infection and speeds recovery. Other uses have been added since.

While robotic surgery is considered generally safe, the FDA is reviewing the data after a growing number of reports of related complications.

As of August 2012, some 71 deaths had been logged by the FDA's online reporting database since the robot was introduced.

And adverse events involving the robot increased 34 percent between 2011 and 2012 alone, prompting the FDA to launch an inquiry. Furthermore, a new Johns Hopkins study shows that such problems are ly underreported.

Still, surgeons see many advantages to performing procedures with a robot.

A computer screen magnifies everything in 3-D, greatly improving the surgeon's field of vision; the robot's “hands” can reach into tighter spots and move in ways that human hands cannot; and the machine's software corrects for a surgeon's hand tremors. The robot may also reduce physician fatigue because surgeons work the robot's controls while sitting at a console instead of standing over the patient for hours.

Minimally invasive robotic surgeries usually result in less blood loss and faster recoveries, since there's a smaller incision to heal. This is a particular advantage for surgeries in which there were few minimally invasive procedures until the robot came along, such as prostate removal and other complex cancer surgeries.

“The system brings the most value when the procedure would otherwise be open,” says Myriam Curet, M.D., the medical adviser of Intuitive Surgical, which manufactures the da Vinci.

Of course there are risks with any type of surgery. But some experts say prospective robotic-surgery patients are rarely told about the risks specific to this high-tech approach.

Some patients, Paul Elliott, have suffered permanent nerve damage due to being held in an unnatural position, as required for some robotic procedures.

Surgeons using a robot don't get the tactile feedback that comes from cutting directly into a patient's tissue, and that can increase the risk of injury from hitting adjacent organs. The machine may also cause burns from the electric current.

Patients may be surprised to learn that there are no national training standards for robotic surgery. The training provided to surgeons new to the technique typically consists of online instruction, a one-day session at the manufacturer's headquarters in California and two supervised surgeries.

It's up to the individual hospital to decide when doctors can perform robotic operations on their own. Yet “it takes a long time to master this technology,” says Jim C. Hu, M.D., director of the robotic and minimally invasive urology surgery program at the University of California, Los Angeles.

Hu has performed more than 2,000 robotic surgeries.

Jesse Lenz

Weigh the pros and cons before considering robotic surgery.

1. Ignore the hype: According to a 2011 Johns Hopkins study, hospital websites often cite studies comparing robotic surgery with open surgery instead of with minimally invasive procedures. “Many claims of superior safety and effectiveness are misleading,” says Marty Makary, M.D., of Johns Hopkins.


Weigh the options: Think twice about having robotic surgery for routine procedures such as hysterectomy, gallbladder removal, hernia repair, appendix removal, gastric bypass and standard colon surgery.

Conversely, the robot's dexterity may pay off for complex cancer surgeries, head and neck tumors, and throat cancer, as well as procedures for which there is no minimally invasive choice.

3. Ask questions: Some patients aren't told that their surgery will be performed with the assistance of a robot, so if you're scheduled for surgery, ask. If a robot will be used, ask whether there are alternatives.

4. Select the right doctor: That is, one who has had practice with the robot — has performed routine surgeries at least 20 times, experts say. UCLA's Jim C. Hu, M.D., advises finding a surgeon who has fellowship training in robotic surgery, and who has practiced robotic surgical skills for more than a year.

The bottom line: It's important to weigh the pros and cons of robotic surgery carefully. Ultimately, your comfort level and your doctor's experience should trump all other considerations.

Beth Howard is a freelance writer.