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Published on : Aug 07, 2014
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Slide 1 - Robotics in Surgery Marc S. Milsten, M.D., F.A.C.S. Urologic Specialists of Oklahoma November 17, 2007
Slide 2 - Definition of a Robot Machine that resembles a human and does mechanical, routine tasks on command Any mechanical device that operates automatically with human-like skill “A robot is not a machine….it is an information system with arms”
Slide 3 - Robots: Better Than Humans?
Slide 4 - Robots: Better Than Humans?
Slide 5 - Types of Robots Passive Retractor system Position the tool and then hold Active Robot would actively move the tool upon the surgeons command
Slide 6 - Surgical Robots in 2007 AESOP (Automated Endoscopic System for Optimal Positioning) - Voice activated mechanical arm - Steadier than human, never tires daVinci - FDA approval in 2002 - Laparoscopic instrumentation controlled by the surgeon positioned remotely at a console
Slide 7 - Development of daVinci Defense Advanced Research Projects Agency (DARPA) for military research of remote battlefield surgery Cholecystectomy performed remotely via telesurgery from 300 miles away Intuitive Surgical created in 1999 after acquiring patent rights from military First robotic prostatectomy performed in 2001
Slide 8 - “Operation Lindberg”: Remote Transatlantic Telesurgery Remote Surgery
Slide 9 - Advantages of Laparoscopic Surgery Shorter hospital stay Less pain Less risk of infection Less blood loss and transfusions Less scarring Faster recovery Quicker return to normal activities
Slide 10 - Challenges of Laparoscopic Prostatectomy Prostate located in fixed confines of pelvis Laparoscopic instruments limited in articulated movements Approximation of bladder-urethral anastomosis difficult to suture French experience: >300 cases reported, learning curve >100 Oklahoma experience: 1 case, 19 hours, patient died
Slide 11 - Advantages of daVinci Robot Magnified (12x), stereoscopic 3-D vision Robotic wrist with 6 degrees of freedom Movements are scaled, filtered, translated
Slide 12 - daVinci Robotic System
Slide 13 - Disadvantages of daVinci Robot Expensive - $1.4 million cost for machine - $120,000 annual maintenance contract - Disposable instruments $2000/case - Hospital reimbursement same DRG Steep surgical learning curve Increased staff training/competance Increased OR set-up/turnover time
Slide 14 - Robotic Disbelievers “No long term data” - Margin positive rates equivalent - No difference in risk for incontinence and erectile dysfunction “Loss of tactile feedback” - Improved vision - Haptic feedback: visual resistance ENABLER: same operation, new tool
Slide 15 - daVinci Robotic Prostatectomy Open Robotic OR time 3 hrs 2-4 hrs Hospital stay 3 days 24 hrs Foley catheter 14 days 7 days Blood loss 600 ml <100ml Recovery 4-6 wks 2-3 wks
Slide 16 - Margin Positivity Series % Positive margins Soloway (Open) 28 % Lepor (Open) 26 % Guillonneau (Laparoscopic) 13.7 % Abbou (Laparoscopic) 20% Rassweiler (Laparoscopic) 24 % Turk (Laparoscopic) 26 % Bollens (Laparoscopic) 22 % Sulser (Laparoscopic) 18% Menon (Robotic) 26%, 17%, 6% Ahlering (Robotic) 17% Lee (Robotic) 21%
Slide 17 - Continence Data Surgeon 3 mo 6 mo 12 mo Walsh (Open) 54 % 80% 93% Abbou (Laparoscopic) 58% 69% 78% Guillonneau (Laparoscopic) N/A N/A 85 % Rassweiler (Laparoscopic) 54% 74% 97% Menon (Robotic) N/A 96% N/A Ahlering (Robotic) 76% 91% 94% Lee (Robotic) 60% 82% N/A
Slide 18 - Potency Data Author Capable of Intercourse Walsh (age 60 to 67) (Open) 75% Catalona (60’s/70’s) (Open) 60% / 47% Guillonneau (Laparoscopic) 66% overall Abbou (Laparoscopic) 54% Turk (Laparoscopic) 59% Menon (Robotic) 64% Ahlering (Robotic) 65% Lee (Robotic) Too early
Slide 19 - Tulsa daVinci Experience Machine located at St. John >130 prostatectomies performed to date Average operative time 2-3 hours >95% patients discharged in <24 hours No conversions to open surgery Complications: 2 post-op bleed, 1 port site hernia, 1 anastomotic stricture
Slide 20 - daVinci Clinical Applications Urology: radical prostatectomy, dismembered pyeloplasty, radical cystectomy, cyst decortication Cardiac: mitral and aortic valve replacement, aorto-iliac bypass, off-pump synchronized bypass GYN: hysterectomy, prolapse repair, tubal reversals, fistula repair, myomectomy General: gastric bypass, Nissen
Slide 21 - daVinci Clinical Limitations No advantage over standard laparscopic approach for cholecystectomy, spleenectomy, colectomy Increased operative time observed Precise dissection not necessary Open space: limitations with broad sweeping motions
Slide 22 - daVinci vs. Laparoscopy Laparoscopic surgical fellow at Stanford First 50 Roux-en-Y procedures randomized laparoscopic or robotic with DaVinci Both surgery with hand-sewn anastomosis OR time: 149 min (lap) vs 131 min (robot) No difference for complications, LOS, EBL Conclusion: Robot is an ENABLER
Slide 23 - Off-pump CABG 30 patients, 2.6 grafts/patient Majority: IMA to LAD 15/30 discharged <24 hours Complications: - 2 return to OR for bleeding - 1 converted to open - 2 readmits: pleural effusion, wound infection No mortality
Slide 24 - Advanced Endoscopy
Slide 25 - Natural Orifice Surgery Courtesy of N Reddy, Hyperbad India 20005
Slide 26 - Courtesy of N Reddy, Hyperbad India 20005 Peroral Transgastric Endoscopic Surgery Natural Orifice Transluminal Endoscopic Surgery (NOTES)
Slide 27 - Trans-gastric Appendectomy
Slide 28 - Climbing the Learning Curve Standard surgery: “see one, do one, teach one” Robotic surgery: “see one, do one, kill one” Requires entirely new skill set beyond traditional surgical and laparoscopic training Training opportunities limited Animal labs helpful Cases require outside proctor to determine competency Credentialing challenges??
Slide 29 - Surgical Simulation
Slide 30 - Surgical Simulation Red Dragon/Blue Dragon
Slide 31 - Hand Motion Assessment
Slide 32 - Robotic Rounding
Slide 33 - Robotic Scrub Nurse “Penelope”
Slide 34 - Robotic Scrub Nurse
Slide 35 - Operating Room of the Future
Slide 36 - Moral Dilemma Technology is neutral - it is neither good or evil It is up to us to breathe the moral and ethical life into these technologies And then apply them with empathy and compassion for each and every patient
Slide 37 - Conclusions The rate of discovery of new technology is outpacing the ability of business, society, and healthcare to integrate and apply Robotic surgery is but one example of such technology that MAY reduce operative morbidity, hospital stay, and recovery, while POTENTIALLY improving clinical outcomes, but at what point do the BENEFITS justify the increased EXPENSE?