Robotic suturing: Technique and benefit in advanced laparoscopic surgery

Abstract

Suturing is one of the main tasks in advanced laparoscopic surgery, but limited degrees of freedom, 2D vision, fulcrum and pivoting effect make it difficult to perform. Robotic systems provide corresponding solutions as three-dimensional (3D) view, intuitive motion and additional degrees of freedom. This review evaluates these benefits for their impact on suturing in experimental and clinical studies. The Medline database was searched for "robot*, telemanipulat* and laparoscop*". A total of 1150 references were found and further limited to "suturing" for experimental evaluation, finding 89 references. All references were considered for information on robotic suturing in advanced laparoscopy. Further references were obtained through cross-referencing the bibliography cited in each work. In experimental studies current robotic systems have proven their superior suturing capabilities compared to conventional laparoscopic techniques, mainly attributed to 3D visualization and full seven degrees of freedom. In clinical studies these benefits have not yet been sufficiently reproduced. Robotic systems have to prove the benefits shown in experimental studies for suturing tasks in clinical applications. Robotic devices shorten the learning curve of laparoscopic procedures. Further clinical trials focusing on anastomosis time are needed to assess this question.

Robotic suturing on the FLS model possesses construct validity, is less physically demanding, and is favored by more surgeons compared with laparoscopy

“…Robotic surgery is a promising new technology with a number of advantages over standard laparoscopy; in addition to making operations from a distance feasible, it offers improved visualization through a three-dimensional imaging system and surgeon-controlled camera manipulation, improved instrumentation with increased range of motion, and downscaling of surgeon's movements that increase precision and improved ergonomics [2,3]. The advantages of robotic assistance over standard laparoscopy have been demonstrated by several studies for novice learners [4][5][6][7], but they are less clear for experienced surgeons.…”

Status of robotic assistance—a less traumatic and more accurate minimally invasive surgery?

“…The surgeon has to accept that dexterity and overview are compromised. The multiple DOF of the hand are limited to only 5 DOF [7]: Pitch, jaw, rotation, extraction/insertion, and instrument usage. In particular, the 2 DOF of the wrist limit instrument handling and dexterity to a great extent [16].…”

“…These benefits are the reason for the worldwide distribution of laparoscopy and explain why minimally invasive techniques are considered standard of care for certain operations, such as cholecystectomy, fundoplication, adrenalectomy, and bariatric surgery [1][2][3][4][5]. Minimally invasive techniques have recently broadened their applicability, moving from simple ablative procedures to more sophisticated reconstructive surgery requiring manipulation in a narrow working space or at non-ergonomic angles for conventional laparoscopy [6,7]. In these cases, the shortcomings of conventional laparoscopy became more evident, especially the limited degrees of freedom (DOF), two-dimensional (2D) view, restricted ergonomics for the surgeon, and the absence of wrist gear [7].…”

“…Minimally invasive techniques have recently broadened their applicability, moving from simple ablative procedures to more sophisticated reconstructive surgery requiring manipulation in a narrow working space or at non-ergonomic angles for conventional laparoscopy [6,7]. In these cases, the shortcomings of conventional laparoscopy became more evident, especially the limited degrees of freedom (DOF), two-dimensional (2D) view, restricted ergonomics for the surgeon, and the absence of wrist gear [7]. Robotic minimally invasive systems might be a viable solution to overcome these handicaps.…”

Robotics in plastic surgery, a review

“…However, the laparoscopic technique carries some drawbacks that limit its application into more complex and reconstructive surgeries. These include limited degree of freedom of movement (4 in laparoscopy vs. 7 for a human wrist), limited vision (2-D systems challenge the surgeon's 3-D imagination), un-ergonomic positioning, presence of the fulcrum effect and amplification of physiologic tremor [14][15][16]; all of these encumber fine dissections and anastomoses [17].…”