Robotics in General Surgery:

Transcription

1 Robotics in General Surgery: Development & Current State Anton Sharapov PGY 4

2 A story of Space, Pentagon, Labrador Dogs & Internet

3 Outline History Impetus for development Definitions Current systems available Applications in General Surgery Application in Pediatric Surgery Credentialing Future developments

4 Definitions Robot- an automated device that performs functions normally ascribed to humans or a machine in the form of a human. Webster

5 Definitions Robot - a reprogrammable multifunctional manipulator designed to move material, parts, tools, or specialized devices through variable programmed motions for the performance of a variety of tasks Robot Institute of America.

6 Definitions A surgical robot a powered device under computerized control can be programmed to manipulate tools to perform surgical tasks

7 Definitions active robot capable of carrying out entire programmed procedure without additional input from the surgeon the surgeon acts as overseer and troubleshooter

8 Definitions A semiactive robot requires input from the operator to perform a procedure aligns surgical tools improves surgeon performance prevents movement outside a safe area of operation

9 Definitions Passive robots do not have powered movement require the surgeon to move the instrument. may hold a rigid position between movements may track movement displays the instrument position on a 3D depiction of the preoperative imaging study.

10 Minimally invasive surgery 1901, Dimitri Ott, ventroscopy 1901, George Kelling, 1 st celioscopy 1910, Jacobeus, series of celioscopies 1966, Kurt Semm, automatic device for insufflation of the abdomen Peritoneoscopy, a diagnostic technique

11 History of MIS Charge Coupling Devise invented, CCD 1985, Sept 12, Erich Mohe, Boblingen, 1 st lap cholecystectomy McKernan & Saye 1988, 1 st lap chole in US Reddick & Olsen popularized technique in NA

12 The Great Expectation Surgeons would apply techniques learned in lap chole to other, more advanced operations Unfounded

13 E.g.: Laparoscopic colectomy Promising for malignant disease Great potential for benign disease However... In US, only 3% of colectomies in 2000 are lap

14 Problems with laparascopy Unstable camera platform Loss of degrees of freedom 2 dimensional video imaging Adverse ergonomics leading to surgeon s fatigue

15 Basic problem Impairment of dexterity due to fulcrum effect of straight instrument loss of sense of touch, haptics, etc. Impairment of vision

16 MAS LAP Wish List Improved visualization The only limits are, as always, those of vision. James Broughton Improved dexterity The king is the man who can. Thomas Carlyle

17 Wandering in The Desert Laparascopic surgery has hit a roadblock somewhere between the technical expertise required for a cholecystectomy and anti-reflux surgery. Only select surgeons are moving beyond these to more technically difficult operations

18 The Promised Land Robots offer the promise of improvements to laparascopic surgery that will allow most surgeons to perform more difficult technical operations. Mark A. Talamini, MD, Director of Minimally Invasive Surgery, Johns Hopkins University School of Medicine

19 Robotics in surgery Science Fiction Karel Chapek, Isaac Asimov, Star Trek Menial tasks -> Anthropomorphism Functionality

20 Asimov s Laws of Robotics 1: A robot may not injure a human being, or, through inaction, allow a human being to come to harm, unless this would violate a higher order law. 2: A robot must obey orders given it by a human being, except where such orders would conflict with a higher order law. 4: A robot must protect its own existence as long as such protection does not conflict with a higher order law.

21 Working with the invisible NASA Ames Research center, 1980s Virtual reality concept Head Mounted display for Voyager Interaction with 3D virtual scenes data glove

22 Telepresence: Beam me up, Scotty... concept of TELEPRESENCE by Scott Fisher

23 Vision gets Enabled NASA meets Stanford Research Institute Blend of virtual reality and applied technology telemanipulator for fine vascular and nerve anastomosis Green Telepresence Surgery System

24 MIS meets robotics 1988 Lap Chole exploded Change of direction towards Macroscopic surgery Army gets involved Advanced Research Projects, Pentagon ARPA net Advanced biomedical technologies

25 Military focus: need for distance surgery Vietnam experience Wound Data and Munition Effectiveness Team Database Survival of critically wounded in the farforward battlefield no change compared to Civil War times 1/3 died, 1/3 mismanaged, 1/3 survived

26 Military: TELE medicine application Bring the surgeon to the wounded soldier Medical Forward Advanced Surgical Treatment (MEDFAST) Damage control surgery through telemedicine

27 Military projects Bradley in the field, surgeon in the MASH 1996, surgery performed over 5 km via microwave communication system successfully demonstrated on animal model change of fighting milieu conventional vs close quarters urban terrain

28 Military progress Solved a number of problems latency (ideally, less then 200 msec latency) 1992, pig liver bix, California-Milan, 1.2 SECOND latency - I.e. can be used with usual geostationary satellite Feasibility Yes, we can Enabled others money to spare Nifty toys

29 US military Trauma Pod : Life Support for Trauma and Transport portable ICU in one bed evacuation system complete monitoring & interventional system

30 Pod compatible with current robotics docked/undocked w/out moving the pt

31 Paradigm shift Civilian vs military needs Telepresence vs Dexterity & Vision enhancement trying to make up for the shortfalls of lap MIS

32 Vets and Labradors 1990, orthoped and a vet, US IBM - puma arm Unimate Puma 2000, initially used to hold instruments for stereotactic biopsy Robodoc - precise (96%) accuracy of femoral rimming prolonged ongoing FDA approval Knee arthroplasty system Acrobot

33 Turps and taters Sir John Wickham, London, Guy s Hospital System for assistance in TURP surgery Probot, U/S registration tested on potatoes, animals, patients, The 1 st semiactive robot to be used on humans

34 The First Breakthrough German experts in nuclear waste managements team, 1989 ARTEMIS advanced robot and telemanipulator system for minimally invasive surgery remote control, highly efficient lost funding, program grounded

35 Need to see Open MRI developed Boston, GE, 1996 image-guided neurosurgical systems real time tracking of instruments in surgery audio feedback to proximity of intended target, audio navigation Stealth Station Swiss NeuroMate system

36 Ability to see AESOP seed money from Pentagon Computer Motion, Inc Automated Endoscopic System for Optimal Positioning the first robot to be FDA approved

37 AESOP clearly demonstrated time & manpower savings with fewer lens cleanings shorter surgical times for some procedures and fewer assistants needed for minimally invasive mitral valve repair Rock steady image EndoAssist in UK

38 Able to see and do Stanford crowd formed Intuitive Surgical, Inc da Vinci system designed April 1997, Brussels the first robotic surgical procedure carried out Computer motion, Inc Developed Zeus

39 Basic Concept for da Vinci & Zeus Dexterity enhancement Vision improvement driven by the physician

40 Set up one endoscopic camera arm Two (or more) robotic arms powered movement of surgical tools guided by a surgeon surgeon at a console with a 3-D view of the operative field

41 Set-up master - slave idea endowrist seven degrees of freedom R& L, up down, in out, rotate L & R, angle L & R, angle up down, and grip on off

42 Robot may modify the surgeon's input removes tremors reduce the scale of the motion allow larger hand movements to control much finer actions magnified endoscopic view Port size 2-5 mm

43 da Vinci Remote manipulator control from a surgical workstation The 3D Insite vision system stereoscopic image over surgeon s hands tele-presence, surgeon is transported instruments are extension of surgeon hands has wrist rotators, 7 degrees of freedom Latest version has 4 arms

44 Zeus Ergonomic design no illusions of being at bedside Initially supped up lap with gizmos Has AESOP, accessory 3 D glasses Older Zeus had only 5 degrees of freedom Zeus-3 has microwrist I.e. 7 degrees Computerized force feed back First crack at haptics

45 Outside show is a poor substitute for inner worth. Aesop

46 How do they compare? Sung et al, Cleveland, 2001 Da Vinci and ZEUS surgical system are comparable for reducing surgeon tremor and fatigue da Vinci significantly shorter operating time more intuitive executions of surgical maneuvers No comparison with current standard of handheld laparoscopy.

47 Lap vs Robot Dakin et al, 2002 First time users, limited basic lap experience only evaluated speed and precision in performing basic and fine laparoscopic tasks First generation Zeus (no endowrist)

48 Basic speed The standard instruments were significantly faster da Vinci was significantly faster than the ZEUS precision da Vinci was more precise than the standard instruments and the ZEUS.

49 Fine 7-0 suturing speed da Vinci and standard instruments were similar both were significantly faster than the ZEUS precision the robotic systems were similar significantly more precise than standard instruments.

50 Robotic Cholecystectomy 5 case series so far Total 123 cases No comparison with lap Da Vinci seems faster then old Zeus Comparable to lap times Better dexterity Visual tension judgement is difficult

51 Adrenalectomy 1992 Gagner et al, lap adrenalectomies the most studied robotic-assisted endocrine procedure Data scarce Piazza et al, 1999, ZEUS AESOP to assist a lap R adrenalectomy for Conn's syndrome operating time of 180 minutes no complications.

52 Adrenalectomy V.B. Kim et al, august 2002 robotic system used to fully assist an adrenalectomy Sung and Gill, Cleveland compared the two surgical systems in 10 pigs da Vinci system boasted shorter operating times (12.2 minutes versus 26.0 minutes; P = 0.006) Surmised 8 to 10 robotic cases are needed before the operating times are comparable to standard lap adrenalectomy.

53 Herniorraphy Even fewer data Reports exist OR time 60 min Big potential, especially w.r.t. precise tacking

54 Bariatric surgery Used for assists Need more elaborate staplers etc Case reports

55 Colon surgery 2002, Merola et al, Compared AESOP to humans in laparoscopic colectomies robotic-controlled camera steadier operative field less camera cleanings no difference complication rate length of hospital stay

56 What s feasible but not necessarily practical Cholecystectomy, Nissen fundoplication, appendectomy, donor nephrectomy, obesity surgery, Heller myotomy

57 ENT endoscopic sinus surgery with 3 D tracking of surgical probes mean accuracy of 2 mm intraoperatively most useful in pts with severe distortion secondary to disease or previous surgery. safety has been demonstrated, No improved outcomes increases in operative time and expense

58 Cardiac Mitral valve repair Assisted and Total IMA mobilization Total CABG, one vessel On & Off pump Beating heart CABG experimental

59 Minimally invasive procedures in pediatric surgery Lap Nissen Lap Splenectomy Lap Chole Laparoscopy Orchedectomy

60 MIS in pediatric surgery, cont d Appendectomy, pyloromyotomy for PS, inguinal hernia, Pectus excavatum repair not widely practiced

61 MIS in pediatric surgery, cont d limited to few Thoracoscopic decortication Thoracoscopic Lung, Mediastinum Bx PDA clipping Anterior spine exposure for fixation Sympathectomy Pneumothorax treatment lap assisted pull through/colectomies/etc.

62 Aesop has been used for... Gastrostomy Pyloromyotomy Pyloroplasty Hernia Diaphramatic Hernia Cholecystectomy Appendectomy Pull-Through for Hirschsprung's Disease Colon Resection

63 AESOP has been used for Trachea Esophageal Fistula Repair Heller Myotomy Splenectomy Nephrectomy Nissen Fundoplication Lung Resection PDA ASD VSD

64 AESOP has been used for... Pyleoplasty Orchidopexy Ureteric Reimplantation Excision of Mediastinal Mass or Tumor Decortication of Empyema

65 Zeus has been used for Pyloromyotomy Pyloroplasty Cholecystectomy Nissen Fundoplication Heller Myotomy Morgagni Hernia

66 Zeus has been used for... Appendectomy Biliary Colon Surgery Lap assisted Pull-Through Splenectomy

67 New procedures in pediatric robotics Animal trial Aesop plus lap vs robotics Zeus 1 & 2 no comparison open vs robotics entero-enteric anastomosis porto-enteric anastomosis hepatico-enteric anastomosis esophageal anastomosis

68 Potential applications For biliary atresia, esophageal atreasia, intestinal atresia Robotics compared to lap, not open lap is not a standard approach

69 Enteroenterostomy, hepaticojejunostomy, and esophagoesophagostomy successfully developed and are technically feasible. The portoenterostomy needs further study to validate data from the second set of experiments, showing a lower complication rate in the robotic group.

70 Reality is Steep learning curves improvements in surgical times are dramatically quick No randomized trials Lots of case reports and feasiblity trials the ultimate goal of any new surgical technology must be to improve patient care

71 Good for... for delicate surgery 10-power magnification instrument maneuverability in small spaces Pediatric surgery Endocrine surgery heart surgery concept of virtual stillness on beating heart ophthalmologic surgery

72 Good for. to allow average joe to do things he thought he never could for the good of the patient and joe Tele-robotics Military projects st transatlantic robot-assisted cholecystectomy, September of 2001

73 Limitations Limited to short distances LATENCY allowed no more then 200 msec next generation Internet, 45 mb/sec optic cable needed better data infrastructure robustness instruments are rudimentary Half-life for da Vinci 10 cases No haptic feedback No match for the hand wrt movement

74 Limitations Rapid surveys with the camera are restricted Setup is less flexible benefit remains to be proven in RCT cost

75 COST AESOP 3000 Endoscope positioner $65,000 Robodoc Active orthopedic robot $600,000 * ZEUS Master slave telemanipulator $800,000 da Vinci MST $1,000,000 CyberKnife Robotic radiosurgery $2,9000,000 Yearly maintenance, ¼ price/year

76 Robotics &Telemedicine Robotics is here First step to telemedicine vision improvement can be applied to any existing procedure that is minimally invasive any lap & thoracoscopy can be improved with a guidance system AESOP is a good start at $ 65,000 US

77 The robotic surgical systems approved by the FDA Stealth and Neuromate passive guidance for now, capable of more The CyberKnife, stereotactic radiosurgery, 6-MV linear accelerator, robot arm with six degrees of freedom

78 The robotic surgical systems approved by the FDA AESOP Robodoc Pending in US, 5000 hips in Europe da Vinci Surgical System For heart only for IMA dissection ZEUS Robotic Surgical System

79 Credentialing Proficiency in open OR is a must Proficiency in basic MAS is a must Proficiency in advanced MAS is a bonus

80 Credentialing Training Course Dismal results with lap chole Large -> small animal lab Preceptorship You observe them Proctorship They observe you Practice

81 The Future Integration of the OR into an efficient unit, trauma pods Preoperative/intraoperative imaging itegration data/image fusion automated decision making tools improved sensory feedback (sound, haptics, touch)

82 The Future Smaller, More reliable, Affordable systems automated procedures Robust informational infrastructure

83 The Future Versatile instruments energy-directed instruments electrocoagulation focused US radiotherapy desiccation ablation

84 The Future... Microelectrochemical systems A fully automated endoscopy system Inchworm, Singapore M2A, Israel nanotechnology

85 I have a dream Year yo retired surgeon needs CABG New coronaries cultured from foreskin fibroblasts Three 4 mm port holes to for surgery No split sternum, no cardiac pillows, no pain Home 2 nd POD Golfing 3 rd POD A happy surgeon

86 References: Robotics and general surgery. Jacob BP - Surg Clin North Am - 01-DEC-2003; 83(6): Robotic surgery: from past to future--a personal journey. Satava RM - Surg Clin North Am - 01-DEC-2003; 83(6): , xii Robotics in surgery. Bann S - J Am Coll Surg - 01-MAY-2003; 196(5): Applications of robotic surgery in pediatric patients. Hollands CM - Surg Laparosc Endosc Percutan Tech - 01-FEB- 2002; 12(1): 71-6 Pediatric surgery. First of two parts. Adzick NS - N Engl J Med - 8-JUN-2000; 342(23): Surgical robotics: the early chronicle: a personal historical perspective. Satava RM. Surg Laparosc Endosc Percutan Tech 2002;12:6-16