Robotic surgery

Information Technology in Medicine: Should patients trust robotic surgery

1 Introduction to the topic

Robots are ubiquitous today. They are found in our cars, in our houses, in our industries inside buildings and to places we neglect to notice. We trust robots to do everyday chores for us either by knowing directly or indirectly. Robots are becoming part of our lives and we have all accepted it.

Today technology has advanced so that it allows for innovative robotic systems to be inserted in the medical field. New materials, ideas and technological advancements bring robotics into medicine. Robotics in medicine entails many advantages and benefits for both the doctors and the patients. But there are also some limitations in robotic surgery that cause doubt and uncertainty to people.

However, as it happens with every new technological development, people need time to become familiar with it, to accept it and finally trust it. So the question is if the world is ready to accept and trust robots in health and more specifically in surgery. There will be people who are pioneers and enjoy trying something new, people who are skeptical and need to know everything about it before agreeing and people who will be afraid no matter how much proof they’re given. There cannot be an abrupt transition from classical surgeries without robots to surgeries all aided with robots. Gradually, the surgeries aided with robots will increase as people’s experience and trust increases.

2 IT Background

2.1 History of robotics

Most of us when we hear the word “robot” we think of science fiction movies showing robots of the future, performing outstanding tasks. In fact, most of these robots seen are now everyday reality making our lives more convenient.

One definition that could be given to a robot is “a reprogrammable multi-functional manipulator designed to move material, parts, tools, or specialized devices through variable programmed motions for the performance of a variety of tasks.[1]

Robotics is the engineering science and technology of robots, their design, manufacturing, and applications. It is related to electronics, mechanics, and software.

ht_2bunimate_080415_sshRobots could not be manufactured until the 1960’s when transistors and integrated circuits were invented. Compact, reliable electronics and a growing computer industry added intellect to the power of already existing machines. In 1959, researchers demonstrated the possibility of robotic manufacturing when they disclosed a computer-controlled milling machine.[2]

The first digitally operated and programmable robot, the Unimate, was installed in 1961 to lift hot pieces of metal from a die casting machine and pile them.[3]

Commercial and industrial robots are ubiquitous in performing jobs better, cheaper, more accurately and reliably than humans. They are also found in jobs that are too hazardous, dirty or tedious for humans.[4]

2.2 Robotics in surgery[5]

Robotics in medicine is a fairly new, yet advancing field. It is now introduced in medicine, in the field of surgery as it allows for exceptional control and precision of surgical devices in minimally invasive procedures. Robotic surgery has as its main goal to design robots that will be able to be used in performing closed-chest, beating-heart surgery in collaboration with the surgeons.

Munich_OR_415Today numerous surgical robots have been adopted by many operating rooms all over the world. Surgical robots are not actually autonomous “surgeons” capable of performing assignments on their own, but a helping assistant of the surgeons.

A number of commercial corporations have been founded in order to create surgical robotic systems. Computer Motion, Inc. developed the AESOP Endoscope Positioner: a voice-activated robotic system for endoscopic surgery.

In January 1999, Intuitive launched the DaVinci Surgical System, which is classified as a master-slave surgical system as it uses true 3-D visualization.

In 2001 Computer Motion, Inc built the SOCRATES Robotic Telecollaboration System as well. It includes integrated telecommunication equipment along with the robotic devices in order to provide remote surgical telecollaboration.

Computer Motion merged with Intuitive Surgical, Inc., in June of 2003.

They introduced the ZEUS Surgical System.

3 Robotic Surgery Systems

Robotic surgery systems are divided into three types: supervisory-controlled systems, shared-control systems and telesurgical systems. These systems differ in the sense that in each case there is a different degree of involvement of the surgeon. In some cases, the operation is carried out by the robotic system with a minimal intervention of the doctor. In other cases, the surgery is performed by the doctor with the help of the robotic system.

3.1 Supervisory-controlled systems [6]

supervisorySupervisory-controlled systems are the most automated systems of all. But they still need the guidance of the surgeon and an extensive preparation before the initiation of the surgery. The surgeon inputs information and programs the robotic system to follow certain instructions. However, once these robots have been programmed, and start operating there is no option for adjustments and that’s why the surgeon must keep a close watch of the surgery in the need of intervention.

As it is known, not all people have the same body structure and so it is not possible to have standard instructions for the robot to follow.

This is done in three stages: planning, registration and navigation.

In the planning stage, the surgeon captures images of the patient’s body. As soon as the surgeon has imaged the patient, he must determine the path that the robot will take to operate.

The next stage is registration, in which the surgeon links the images obtained before with points on the patient’s body. In order for the surgery to be completed successfully, the points must be positioned precisely according to the patient’s body.

The final stage is navigation, which is the actual surgery. In this stage the surgeon places the patient and the robot so as the movements of the robotic system to follow the programmed instructions. When all preparations are complete, the robot is activated and the surgery is carried out.

3.2 Shared-control robotic systems[7]

Shared-control robotic systems are a helping hand for the surgeons. The operation is carried out only by the surgeon who uses the robotic system manually in order to have greater efficiency. The robotic system monitors the surgeon’s actions during the operation and provides support and stability by “active constraint”.7

“Active constraint” is the process of labelling regions of the patient’s body with one of the four possibilities: safe, close, boundary and forbidden. Surgeons label safe regions the regions that are appropriate for the robot to be and to operate. For instance, a close region can be found in orthopaedic surgery in orthopaedic surgery, near the soft tissues. Many orthopaedic surgery tools can damage the soft tissue and so the robot limits the area that the surgery is safe to take place.

This is done using “haptic” technology[8], which is the science and physiology of the sense of touch. This means that as the surgeon approaches the boundary region he will start feeling a resistive force and as he proceeds to the forbidden region the force is getting larger and once he enters the forbidden region the robotic system stops operating immediately.

But in order for the robotic system to know which are those regions, the surgeon must program it first as it is done with the supervisory controlled systems.

3.3 Telesurgical systems [9]

Telesurgery is a field of telemedicine that was developed in recent years and holds great interest. Today it can be seen as a two way transmission of picture and sound, allowing the communication between surgeons of little experience and surgeons of great experience to cooperate no matter the distance separating them.

Also it is understood, this technology needs highly advanced software in order for the simulation to be feasible in the remote surgery room. For this purpose, systems of virtual reality are required that allow the surgeons that are in a different room or city or country to have an actual image of the operating room and of the procedure. Robots with camera will provide a better quality of the images as they will be in colour and enlarged.

3.3.1 Da Vinci Surgical System [10]

The Da Vinci Robot is probably one of the most well-known robotic surgery systems in the world. It is a robotic system that is used in minimally invasive surgery, which means that the robot makes a petite aperture in the patient’s body that brings many positive results.

DaVinci-Robot During the surgery, the surgeon sits in a console inside the operating room and handles the surgical tools of the robot. After the patient has been anaesthetized, three apertures are made on the patient’s body allowing the rods to enter. On the screen the surgeon observes the 3D image that the camera is transmitting through the patient’s body and which is handled by joysticks. The camera sees every movement of the robot and can be activated or deactivated any time from a button.[11] Every surgical arm is connected with a surgical tool and there is camera in the end of the main arm. One of the rods has a camera on it while the others have surgical tools able to cut, remove or stitch the tissues. The robotic system uses the same stitches and materials used in the traditional surgery.

The surgeon can bend and rotate the arms like the human wrist guaranteeing increased percentage of success and important benefits much for the patient as for the surgeon.

The Da Vinci robotic system includes a lenses system of three-dimensional view, which can make the surgical field as 15 times larger. Also, the camera allows the surgeon to go closer at the point of surgery than the human vision can and so the surgeon can perform the operation in a smaller scale than the conventional surgery allows.

3.3.2 Zeus Robotic Surgical System[12]

The robotic surgical system Zeus was the first system to be used in 1999 to perform the first full endoscopic robotic surgery bypass with a beating heart.

It consists of three basic parts:

1. 1zeusconsoleAn ergonomic control console

2. the central control computer

3. Robotic arms, which move with the movement of the surgeon’s hand.

The surgeon sits comfortably in the surgical seat and handles the tools that are placed inside the patient. After the surgeon’s movements have been digitalized they are filtered, thinned and transmitted to the computer’s control station, which transfers those movements through an electromechanical interface to the robotic arms and to the tools.

In addition, Zeus robotic system enhances the optical field of the surgery by enlarging it and also with the help of AESOP robotic system the surgeon’s hands are free to handle the surgical tools.

3.3.3 AESOP Robotic Surgical System [13]

AESOP Robotic surgical system was developed by Computer Motion Inc. The period when it first came out, the surgeon could control the robotic arm remotely, manually or with a foot pedal but the most recent edition of AESOP 3000 is controlled with voice commands.

The robotic arm contains and moves a camera which is used in MIS surgeries for the observation of the surgical field. The camera is placed at the edge of the robotic arm and is inserted in the patient’s body through an aperture of about 2cm. The robotic system AESOP is the surgeon’s third arm. By using simple commands such as “AESOP, move up” or “AESOP, move left”, the surgeon tells the robot to move the camera as he wishes. Every surgeon records his voice and has a voice card that is inserted into the system whenever he operates, in order for the robot to identify the commands. Usually the system works well. The robot may sometimes not recognize the tone of the voice of the surgeon is different from the recorded voice. But there is a support system with which the surgeon can handle manually if something like this happens.

3.3.4 SOCRATES Telecollaboration System [14]

Socrates telecollaboration system was the first system to be approved (October 2001) for the new-founded category “telesurgery robotic systems”. It consists of advanced telecommunication equipment that is connected with medical devices and robotic systems. The system gives the surgeon who is at a remote location the opportunity to work with another surgeon who may be in an operating room across the globe. The system provides real time view of the surgery. In collaboration with Zeus robotic system, Socrates is the first fundamental step that marks the start of minimally invasive telesurgery. In 2001 Socrates robot along with Zeus robotic system performed the first translantic surgery. On September 7th, 2001 a group of surgeons in New York performed a cholecystectomy surgery on a patient located in France with the help of doctors that were there. The console and the robot were connected with fiber optic wires. This surgery was first tested on six pigs.That was the first complete telesurgical process that was performed by surgeons 7000 away from their patient. The patient left the hospital 48 hours after the operation and returned to his social activities a week later.

4 Advantages and Limitations [15]

4.1 Advantages

The advantages of robotic surgery are listed below:

1. Tinniest incisions result in:

* Faster recovery

* Shorter hospital stay and reduced costs

* Less pain and fear

* Less blood loss

* Cosmetic benefit

* Reduced risk of infection or complications

* Less anesthesia required

2. Better sterilization

3. Robot immune to radiation and infections.

4. No muscle tremor or fatigue.

5. Elimination of need for personnel resulting in lower costs for the hospitals.

6. Shorter return to everyday activities(1-2 weeks)

7. Telesurgery: The ability to perform surgery from a different operating room.

8. A 3D camera provides an enhanced view.

9. Robots reach places that surgeons alone couldn’t before.

10. Can be designed for a wide range of scales.

11. Surgeons don’t get tired quickly as they’re seated and have less eye strain and they have the ability to control their natural flinching or nerves more effectively.

4.2 Limitations

However some of its disadvantages and concerns are:

1. Robotic systems have highly complex software and it is very difficult to program and debug them.

2. Costs including the robotic systems ($750.000-$1 million), the maintenance and the training of surgeons are considerably high.

3. Since the need of personnel will be minimized, some surgeons will be left unemployed.

4. Telesurgery is based by a large percentage on the transmission of information between two locations. The more the distance between the two locations the more the time delay is inserted. This increased the period between the action and the result and after a certain point this makes surgery impossible in real time.

5. Synchronization during telesurgery is very critical and is not easy to attain.

6. Telesurgery is highly dependent on the security and reliability of the network.

5 Robotic Surgery in Greece [16]

The first robotic navigation system used in a surgery procedure in Greece is the Vector Vision II system in “Ygeia” (see www.ygeia.gr) hospital in Athens.

In February 2003 the robotic surgical system “Aesop 1000” was used to perform the first laparoscopic operation in the General Hospital of Crete, Greece.

“Aesop 1000” is being improved in the labs of University of Crete and will be released as “Aesop 2000” and “Aesop 3000” and soon is expected to be used in more complex operations and surgeries.

In addition, the school of medicine in the University of Athens offers advanced courses on robotic surgery. The course aims to teach basic robotic surgery skills such as instrument manipulation, camera control among others. This is done using the Da Vinci surgical system.[17]

1stdayIn November 8th,2006 the opening day of the Da Vinci robotic system took place in the Athens Medical Center Hospital.

The president of the Hellenic Scientific Robotic Surgical Association Prof. K. Konstantinidis explained the fundamental principles of the Da Vinci robot to Greek ministers and the establishment of the Hellenic Scientific Society of Robotic Surgery.

The first total hysterectomy in Greece was successfully carried out with the latest-generation Da Vinci Robotic Surgery System at the Diagnostic and Therapeutic Centre of Athens – HYGEIA. the operation was broadcasted in real time during the daily conference held at the Hospital on Tuesday, July 1st 2008, titled “Robotic Surgery in Gynaecology”.[18]

5.1 Survey analysis

A survey was conducted during October and November 2009 in Athens about robotic surgery, in which 73 people answered (ages 14-50). The survey included a questionnaire and it was distributed by email. Robotic surgery in Greece is in its infancy so it is quite reasonable to see that 72% of the people asked knew nothing about robotic surgery.

6 Social Concerns

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