Robotics and telesurgery – an update on their position in laparoscopic radical prostatectomy

Abstract

Laparoscopy is handicapped by the reduction of the range of motion from six to only four degrees of freedom. In complicated cases (i.e. radical prostatectomy), there is often a crossing of the hands of surgeon and assistant. Finally, standard laparoscopes allow only 2D-vision. This has a major impact on technically difficult reconstructive procedures such as laparoscopic radical prostatectomy. Solutions include the understanding of the geometry of laparoscopy, but also newly developed surgical robots. During the last five years, there has been an increasing development and experience with robotics in urology. This article reviews the actual results focussing on the benefits and problems of robotics in laparoscopic radical prostatectomy. Own experiences with robot-assisted surgery include more than 1200 laparoscopic radical prostatectomies using a voice-controlled camera-arm (AESOP) as well as six telesurgical interventions with the da Vinci-system. Substantial experimental studies have been performed focussing on the geometry of laparoscopy and new training concepts such as perfused pelvitrainers and models for simulation of urethrovesical anastomosis. The recent literature on robotics in urology has been reviewed based on a MEDLINE/PUBMED research. The geometry of laparoscopy includes the angles between the instruments which have to be in a range of 25 degrees to 45 degrees ; the angles between the instrument and the working plane that should not exceed 55 degrees ; and the bi-planar angle between the shaft of the needle holder and the needle which has to be adapted according to the anatomical situation in range of 90 degrees to 110 degrees . 3-D-systems have not yet proved to be effective due to handling problems such as shutter glasses, video helmets or reduced brightness. At the moment, there are only two robotic surgical systems (AESOP, da Vinci) in clinical use, of which only the da Vinci provides stereovision and all six degrees of freedom (DOF). To date, more than 3000 laparoscopic radical prostatectomies have been performed worldwide at 92 centres with this system. The main advantage of the system represents the translation of open surgical skills to laparoscopy. Despite recent development of basic tools (e.g. bipolar forceps) for the da Vinci robot, investment and maintenance costs still represent the major problem of the device. Additionally, the device does not provide any haptic sense (i.e. tactile feedback). Robotic surgery represents a turning point of surgical research. However, broad use of robotic systems is limited mainly because of the high investment and running costs. Interestingly, more than in the field of cardiac surgery, there seems to be a need for telemanipulators in urology, mainly to reduce the learning curve of standard laparoscopy. However, new training concepts used in combination with mono-tasking computerized robots (AESOP) have proved their efficacy associated with a significant cost reduction.

Visual clues act as a substitute for haptic feedback in robotic surgery

“…Because tactile ability is an essential element of surgery, many concerns arise when there is a complete lack of tactile feedback in robotic surgery [5,7,8,10,12]. It is evident that scientific effort will be required to develop devices that provide the surgeon with haptic feedback, but this feature is not expected to be commercially available for the da Vinci 1 robot in the near future [9,11].…”

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

“…The natural 3D view of the manipulated tissue is exchanged for a distanced 2D video image of reality [18]. The disparity between the position of the monitor and the patient can cause considerable nonergonomic and even awkward positions for the surgeon, due to the fixed placement of the trocars [16]. Nonetheless, the surgeon has a significantly reduced tactile feedback, making it almost impossible to distinguish tissue by touching it [19].…”

“…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]. In addition, every movement inside the abdomen has to be mirrored outside, owing to the fulcrum effect, causing contra-intuitive movements that create considerable mental workload, at least for the trainee laparoscopic surgeon [17].…”

Telesurgical evaluation of stable thoracic trauma patients: a feasibility study

“…Since this study was performed, however, considerable advances have been made in robotic platforms, endoscopic instrumentation, and wireless communications. A great deal of experience and success with robotic surgical operations have been achieved with urologic, cardiac, and complex gastrointestinal procedures [5][6][7][8][9][10], including transforming these towards more of a true telesurgical model, where the operator manipulates the surgical robot remotely from its location.…”