New technologies herald a new era for robotic laparoscopic surgery

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Advances in robotic and computer technology, in addition to physician training, could see robotic laparoscopic aortic surgery become a mainstream procedure within years. This is the view of Professor Willem Wisselink, Chief, Division of Vascular Surgery, VU University Medical Center, Amsterdam, the Netherlands.

Wisselink believes that laparoscopic vascular surgery, despite bringing numerous benefits to the patient, physicians and healthcare systems, alike, has yet to achieve the adoption rate the procedure deserves. Wisselink commented, “Despite world-renowned surgeons such as Gracia, Dion, Cuesta, Alimi, Cau, Kolvenbach, Remy and Coggia, all embracing laparoscopic developments there seems to be a problem with laparoscopy in vascular surgery.” Wisselink claims that this is due to certain limitations with the conventional laparoscopy procedure. For example, the operator is faced with certain constraints such as the lack of 3D visualisation, limited tactile feedback, restriction in the degrees of freedom of movements because of non-articulating laparoscopic instruments and a fixed point of insertion, mirroring of hand movements, potential inaccuracy during delicate reconstruction because of natural hand tremor, awkward hand-eye coordination and interior ergonomics.

Nevertheless, the benefits of laparoscopic surgery compared with open surgery are well documented. For example, due to the minimally-invasive nature of the laparoscopic technique there is a reduction in pain and trauma to the body, with less post-operative pain and discomfort for the patient. Laparoscopic surgery reduces trauma to the patient by allowing surgeries to be performed through small ports rather than large incisions, resulting in less blood loss and a reduced need for transfusions, which in turn, this decreases the risk of infection. As the technique is less traumatic to the patient hospital costs are reduced and the patient benefits from faster recovery times and reduced hospitalisation costs. The patient also benefits from less scarring and improved cosmesis.

According to Wisselink, laparoscopic surgery has suffered to date due to the lack of technology, “However, with recent developments such as the da Vinci robotic surgical system (from Intuitive Surgical), and Computer Motion being taken over by Intuitive Surgical (although the Zeus isn’t for sale anymore), we now have the technology required.”

The da Vinci system consists of three components a surgeon console with an integrated 3D display stereo viewer, a robotic manipulator with three or four cartmounted arms (one arm for the camera, two arms for the 8 mm instruments), and a vision cart. Visualisation is obtained by two three chip cameras mounted within one integrated, 3D 12mm stereo endoscope with two separate optical channels. The laparoscope is controlled by moving the master robotic handles. The operative images are transmitted to a high resolution binocular display at the surgeon console. Laparoscopic instrument tips, called “Endo wrist instruments”, provide articulated motion with a full seven degrees of freedom inside the abdominal cavity. Tip articulations mimic the up/down (pitch) and the side-to-side (yaw) flexibility of the human wrist. In addition, instrument tips are aligned with the instrument controllers electronically to provide optimal hand-eye orientation and natural operative capability.

In a study on 20 pigs, comparing robotic laparoscopic surgery with standard laparoscopic surgery, Wisselink and co-workers inserted a tubegraft in the infrarenal aorta. The outcomes demonstrated that the robotic technique was better, faster, with lower blood-loss compared to standard laparoscopy.

Furthermore, in a clinical study of 20 consecutive patients (aged 33 to 63 years), who underwent a robot-assisted laparoscopic aortobifemoral bypass (14 suffering from severe claudication and six from limb threatening ischaemia), Wisselink also reported a primary patency rate of 95% after a follow-up period of 9-31 months. In addition, the results demonstrated that familiarity with the procedure and technology reduced the operative (median 355 minutes) and clamp (85 minutes) times. The study also reported an average hospital stay of four days.

So what is the future for Robotic laparoscopic surgery? Wisselink commented, “The current robotic surgical equipment probably represents an inbetween, evolving technology that is still rather bulky and expensive. But as the technology advances the potential to make significant leaps in robotic laparoscopic surgery will be realised.”

The evolution in robotics will also result in smaller, simpler and cheaper technologies, this coupled with the flaws in current endografts could “leave the door open” for robotic laparoscopic surgery to be used in more indications, such as abdominal aortic aneurysm repair in fit patients.

Wisselink acknowledges that plain laparoscopic vascular surgery is just too difficult to become mainstream. The current status of robotic technology means that robotic laparoscopic vascular surgery may not be quite ready for mainstream use. “However, new technologic advances will drastically change this. Many hope this is all just a gimmick. I don’t. I advise vascular surgeons to keep up with their laparoscopic skills in anticipation: abdominal incisions will become history sooner than you think.”

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