Robotic surgery

Written by: 
Suzi Lewis-Barned, medical writer

Robotic surgery involves the use of robotic devices in the performance of surgical procedures. Since 1985, when a robot was first used to place a needle for a brain biopsyThe removal of a small sample of cells or tissue so that it may be examined under a microscope. The term may also refer to the tissue sample itself.,1 the use of robotic surgery has increased, especially for urologicalRelating to the urinary tract. procedures.

The robots used by surgeons are devices with mechanical arms capable of holding and using instruments with great dexterity, precision and accuracy.

In some cases surgeons use robotic devices to perform a step in a process. In other cases, entire procedures may be performed robotically - that is, with a computer and robotic device under the control and supervision of the surgeon.

Robotic surgery is most often used in minimally invasive surgery, also known as keyhole surgeryA type of minimally invasive surgery.. Robotic surgery has helped to promote the more widespread use of minimally invasive surgery by enabling surgeons to operate with a completely steady hand, providing the high degree of accuracy required for this type of procedure.

Some experts see the use of robots as the future of surgery, although there is still considerable debate about the usefulness and cost-effectiveness of robotic surgery techniques.2

The main points of interest and concern are:

What types of robotic surgery are available?

The types of robotic surgery are distinguished by how the workload is divided between surgeon and robot.3

Shared-control procedures

In shared-control procedures, robots are used to position limbs carefully or to hold steady pieces of equipment, including cameras. They may also be used to access areas of the body that are difficult to reach, while avoiding hand tremor.

Remote/telesurgical procedures

In 2001 the first transatlantic telesurgery procedure took place, whereby a surgeon in New York City, USA, performed a gall bladderThe organ that stores urine. operation on a patient 4,000 miles away in Strasbourg, France

In remote/telesurgical procedures, a surgeon is able to perform surgery on patients at a distance. As with shared-control procedures, robots can be used to access areas of the body that are difficult to reach, while also avoiding hand tremor.

In these procedures surgeon and patient can be many miles apart. On 7 September 2001 the first transatlantic telesurgery procedure took place. In this procedure, known as 'Operation Lindbergh', a surgeon in New York City, USA, performed a minimally invasive gall bladderThe organ that stores urine. operation on a patient 6,500 kilometres (4,000 miles) away in Strasbourg, France. During the procedure the surgeon's hand movements in New York City were transmitted by high-speed fibre-optic cable and replicated by robotic instruments in France; an endoscopic camera was also used to allow the surgeon to see what was happening inside the patient's body.4

Through the use of high-speed fibre-optic cable, the operation overcame one of the principal obstacles associated with such teleprocedures - 'latency', the time delay between the surgeon moving his or her hands and the robotic arms responding to those movements.

Supervisory controlled procedures

In supervisory controlled procedures, the surgeon's role is to prepare and plan the procedure, program the robot and then oversee the operation. He or she will not become directly involved in the operation, unless there is a problem.

The first unmanned robotic surgery took place in May 2006 in Italy. The 50-minute surgery was carried out on a 34-year-old patient suffering from atrial fibrillationA common abnormal heart rhythm causing a rapid, irregular pulse and failure of the upper chambers of the heart (atria) to pump properly. Abbreviated to AF. (abnormal heart rhythm).5

As well as enabling specialist surgeons to use their expertise in remote or difficult locations, this procedure can significantly reduce patient trauma that might otherwise arise from less precisely guided operations.

Such procedures are only possible once the area where the operation is to take place has been fully mapped using tools such as computerised tomographyA scan that generates a series of cross-sectional X-ray images. (CT) scans, magnetic resonance imagingA technique for imaging the body that uses electromagnetic waves and a strong magnetic field. (MRI) scans, ultrasonography, fluoroscopyThe use of an image intensifier and TV monitor to view X-ray images. or X-ray photography.

What are the advantages, issues and difficulties of robotic surgery for patients?

The advantages of robotic surgery for patients include:

  • Reduction of tremor and fatigue in surgeons
  • The robotic surgery machines are resistantA microbe, such as a type of bacteria, that is able to resist the effects of antibiotics or other drugs. to infectionInvasion by organisms that may be harmful, for example bacteria or parasites.
  • Pre-programmed movements enable great precision and accuracy
  • Consistent performance improves the quality of a procedure
  • The procedure offers the potential for increasing the range of operations that can be undertaken using minimally invasive surgery
  • The procedure reduces the time taken for routine operations
  • Smaller incisions mean less trauma
  • Fewer complications
  • Decreased bloodA fluid that transports oxygen and other substances through the body, made up of blood cells suspended in a liquid. loss
  • Less pain
  • Quicker healing time, less time in intensive care and inpatient units
  • The procedure avoids the problems that may otherwise arise following standard splitting of the sternum (sternotomySurgical opening of the breastbone.) and making of chest-wall incisions (thoracotomyOpening of the chest cavity during surgery.) in patients undergoing heart surgery.6,7

Some of the potential issues include:8

  • High costs of the equipment mean that routine operations using robots may be less cost-effective than standard procedures, particularly where robotic procedures are also associated with longer operating times compared with non-robotic techniques
  • There can be problems for surgeons in communicating with their assistants
  • Technical problems sometimes arise, including malfunction and collision of instruments
  • While robotic surgery is potentially faster than conventional surgery, this is not always the case in practice
  • It is difficult for surgeons specialising in robotic surgery to maintain their skills because there are so few cases involving robotic surgery
  • Robots lack human judgement - they can only do what they have been programmed to do.

When is robotic surgery used?

Urology - localised prostate cancer

Laparoscopic radical (or total) prostatectomy is the most common procedure carried out using robotic surgery - with the da Vinci robot. In the USA in 2007, about 60 per cent of all radical prostatectomies were performed with robot assistance.9 The removal of a kidney (nephrectomyThe surgical removal of a kidney.)10 and pelvic lymph node dissection11 have also been performed using robotic surgery.

Radical prostatectomy, which can be performed in a number of different ways, involves removal of the entire prostate and all or part of the seminal vesicles in male patients. However, surgery is not the only treatment available for this condition.12 Read more about surgical treatment of prostate cancer.

Some head and neck cancers

Robot-assisted surgery appears feasible for treating some cancers arising in the head and neck. However, its use in this area is still at an early investigational stage.7

Other cancers

Robotic surgery is also used to treat various other cancers including those in the oesophagusThe gullet, the part of the gastrointestinal system that extends down from the mouth cavity to the stomach., in gastric cancerAbnormal, uncontrolled cell division resulting in a malignant tumour that may invade surrounding tissues or spread to distant parts of the body. and in colonThe large intestine. cancerAbnormal, uncontrolled cell division resulting in a malignant tumour that may invade surrounding tissues or spread to distant parts of the body., and in guiding treatment of various cancers with radiotherapy.

Gastrointestinal surgery

Robotic surgery is used for a number of procedures in gastrointestinal surgery, including:

  • Removal of the gall bladderThe organ that stores urine. (cholecystectomyThe surgical removal of the gallbladder.)
  • Operations to prevent reflux of acid from the stomach into the oesophagusThe gullet, the part of the gastrointestinal system that extends down from the mouth cavity to the stomach. (anti-reflux surgerySurgery to prevent reflux, or the backflow of liquid.)
  • Heller's myotomy, an operation in which muscles at the junction of the oesophagusThe gullet, the part of the gastrointestinal system that extends down from the mouth cavity to the stomach. and stomach are cut to allow liquids and food to pass into the stomach, correcting the condition of achalasiaFailure of the muscle around the lower opening of the oesophagus (the lower oesophageal sphincter) to relax. in which the lower oesophagusThe gullet, the part of the gastrointestinal system that extends down from the mouth cavity to the stomach. fails to relax as it should, so restricting passage of liquids and food
  • Gastric bypass, in which the digestive system is shortened, bypassing part of the small intestineThe section of gut, or gastrointestinal tract, from the stomach to the anus., as a treatment for obesityExcess accumulation of fat in the body.
  • An operation (gastrojejunostomyA surgical procedure in which the jejunum, part of the small intestine, is joined to the stomach.) in which the stomach is surgically connected to the small intestineThe section of gut, or gastrointestinal tract, from the stomach to the anus. (jejunum), often performed in cases of cancers of the gastrointestinal tractThe gut, which begins at the mouth and ends at the anus.
  • Removal of part of the oesophagusThe gullet, the part of the gastrointestinal system that extends down from the mouth cavity to the stomach. and stomach (oesophagectomyThe surgical removal of all or part of the oesophagus, or gullet.), performed to treat cancerAbnormal, uncontrolled cell division resulting in a malignant tumour that may invade surrounding tissues or spread to distant parts of the body. of the oesophagusThe gullet, the part of the gastrointestinal system that extends down from the mouth cavity to the stomach.
  • Gastric banding, fitting a band around the upper part of the stomach to treat obesityExcess accumulation of fat in the body.
  • Colectomy, removal of part or all of the large intestineThe section of gut, or gastrointestinal tract, from the stomach to the anus. (colonThe large intestine.)
  • Removal of the spleen An organ situated on the left side of the abdomen that filters out worn-out red blood cells and other foreign bodies from the bloodstream.(splenectomy)
  • Removal of one or both adrenal glands (adrenalectomyThe surgical removal of one of the two adrenal glands. The adrenal glands sit on top of the kidneys and produce adrenaline.)
  • Removal of parts of the pancreas A gland behind the stomach that produces digestive enzymes and the hormones insulin and glucagon, which together regulate glucose levels in the blood. (pancreatic resectionThe surgical removal of the pancreas).

The first robotically performed kidney and pancreas transplant from a living donor took place in January 2006 in Chicago, USA.13

Gynaecological surgery

Robotic surgery may be used for various procedures including hysterectomy and microsurgical repairing of blocked Fallopian tubes (Fallopian tube reanastomosisThe surgical reattachment of two tubular organs within the body.).

Cardiothoracic surgery

Robotic surgery may be used for coronary bypassSurgery that bypasses a blockage in a segment of an artery supplying the heart (coronary artery), using a section of a vein or artery from elsewhere in the body. and other heart operations, including replacement of the mitral valveA valve in the heart located between the left atrium (one of the two upper chambers of the heart) and the left ventricle (one of the two lower chambers)., atrial septal defect repair and repair of a gap in the atrial septum, often known as a 'hole in the heart'.

Paediatric surgery

Robotic surgery has been used for procedures including anti-reflux procedures for gastroesophageal reflux diseaseDisease caused by the abnormal movement of stomach contents back up the oesophagus, or gullet.,14 and treatment for paediatric congenitalAny condition present since birth. heart diseases.15

References: 
  1. Kwoh YS, Hou J, Jonckheere EA, et al. 'A robot with improved absolute positioning accuracy for CTA scan that generates a series of cross-sectional X-ray images. guided stereotactic brain surgery' IEEE Trans Biomed Eng. 1988; 35: 153-160.
  2. Murphy D, Hall R, Tong R, et al. 'Robotic technology in surgery: Current status in 2008' ANZ Journal of Surgery, 78(12): 1076-1081.
  3. 'Robotic surgery'. Brown University Division of Biology and Medicine, Brown University, Providence, RI 02912, USA. Link (accessed 16 September 2009)
  4. 'Doctors claim world first in telesurgery'. BBC News Sci/Tech. Link (accessed 8 September 2009)
  5. 'Robot carries out operation by itself'. Physorg.com. Link (accessed 25 August 2009)
  6. 'Surgical robots'. University of Birmingham National Horizon Scanning Centre New and Emerging Technology Briefing. Link (accessed 25 August 2009)
  7. Boudreaux BA, Rosenthal EL, Magnuson JS, et al. 'Robot-assisted surgery for upper aerodigestive tract neoplasms' Arch Otolaryngol Head Neck Surg. 2009; 135(4): 397-401.
  8. Heemskerk J, Van Dam R, Van Gemert WG, et al. 'First results after introduction of the four-armed da Vinci Surgical System in fully robotic laparoscopic cholecystectomyThe surgical removal of the gallbladder.' Digestive Surgery. 2005; 22(6): 426-431.
  9. 'Robotic surgery'. University of Winsconsin Health Sciences, University of Wisconsin Hospitals and Clinics Authority. Link (accessed 16 September 2009)
  10. Guillonneau B, Jayet C, Tewari G, et al. 'Robot-assisted laparoscopic nephrectomyThe surgical removal of a kidney.' The Journal of Urology. 166(1): 200-201.
  11. Bilal Sert M, Eraker R. 'Robot-assisted laparoscopic surgery in gynaecological oncology: Initial experience at Oslo Radium Hospital and 16 months follow-up.' The International Journal of Medical Robotics and Computer Assisted Surgery. 2009; 5(4): 410-14.
  12. 'Laparoscopic radical prostatectomyThe surgical removal of the entire prostate gland.'. British National Health Service (NHS) National Institute for Health and Clinical Excellence. November 2006. NICE, IPG 193, accessed 25 August 2009.
  13. 'UIC surgeons first to use robot for living donor kidney pancreas transplant'. Link (accessed 19 September 2009)
  14. Aurora AR, Talamini MA. 'A comprehensive review of anti-reflux procedures completed by computer-assisted tele-surgery.' Minerva Chirurgica. 2004; 59(5): 417-26.
  15. 'Congenital Heart Center: Robotic Mitral Valve Repair'. The University of Chicago Children's Hospital. Link (accessed 19 September 2009)