[ Editorials | Letters | Selected Articles | Signature Series | Patient Handouts | Index ]

OB/GYN Editorial July 2004

This Is My Assistant, Dr Robot

Arnold P. Advincula, MD

Since the advent of modern-day endoscopy, technology surrounding minimally invasive surgery has grown by leaps and bounds. In gynecology, the days of a surgeon peering through an eyepiece during a diagnostic laparoscopy have long passed. Today, three-dimensional (3-D) imaging is possible for both the surgeon and observers while complex procedures are performed with advanced laparoscopic instrumentation. Studies have clearly shown that laparoscopic surgery allows for faster recovery with less postoperative pain. Despite these technological advancements and benefits, more complex procedures such as hysterectomy, the management of advanced endometriosis, and procedures that require extensive suturing (eg, myomectomy, pelvic reconstructive surgery, tubal reanastomosis) are typically still managed by laparotomy. In their quest to perform more procedures in a minimally invasive fashion, modern-day surgeons are challenged by the limitations of conventional laparoscopy in addition to the issues surrounding training and acquisition of advanced skills.

Advancements in laparoscopy have brought us high-intensity xenon and halogen light sources as well as three- chip cameras. On the other hand, the lack of depth perception due to two-dimensional imaging, rigid instruments with a limited range of motion that is counter-intuitive, and poor ergonomics for the surgical team remain significant limitations to performing complex procedures in a minimally invasive fashion. One solution to this problem has been the introduction of robotic technology to the operating theater. Originally, the concept of robot-assisted surgery was borne out of the military's desire to develop remote battlefield surgery whereby the surgeon would be at a distant location and a robot placed as close as possible to the injured soldier. Soon the idea spilled over to the civilian sector. The first example of this technology was the use of a voice-activated robotic arm known as Aesop to operate the camera during laparoscopic surgery. One study compared the system to a surgical assistant holding the laparoscope during gynecologic surgery.¹ The authors found that the time required to perform surgery was faster with the robotic camera holder because it allowed the two surgeons to use both hands for operating. Currently, the US Food and Drug Administration has approved two robotic systems for use in operative laparoscopy: Zeus and da Vinci.

The robotic systems consist of three components. The first is the console where the surgeon sits and controls the robotic arms while viewing a 3-D operative field. Wrist-like instruments that avoid the fulcrum effect seen with conventional laparoscopy are manipulated at the console. The second component is the robotic arms that hold the instruments. The final component is the computer interface and vision system that provide the improved imaging and translate the mechanical movements of the surgeons' hands into computer algorithms that direct the robotic arms and instruments.

The use of robotic technology to facilitate laparoscopic procedures has increased over the past decade. In numerous studies across various disciplines, it has been shown to be a safe and effective alternative to conventional laparoscopic surgery, particularly when dealing with complex pathology. In the area of gynecology, there are reports of robot-assisted laparoscopy for tubal reanastomosis, ovarian transposition, hysterectomy, and repair of vaginal vault prolapse.^2-5

Robot-assisted surgery has not only addressed many of the current limitations of conventional laparo-scopy but may also provide a way to improve surgical training and the acquisition of advanced skills. Many complex gynecologic procedures are still performed via laparotomy and one reason is the lack of laparoscopic surgical training. A prime example is the rate of laparoscopic hysterectomy in France. One study reported that out of 23 French medical centers, only nine centers carried out total laparoscopic hysterectomies, and that training was found to be a major factor in the choice of technique.⁶ It is well documented that operative laparoscopy has a lengthy learning curve before competence is high and complication rates are reduced.⁷ Even when surgical training is available, this lengthy training interval to attain laparoscopic competence has often remained an obstacle to gynecologic surgeons.

The use of robot-assisted laparo-scopy may rapidly bridge the gap between assimilation of new techniques and the actual application of the procedures. A recent study evaluated robotic technology in the area of training and acquisition of advanced skills. The impact of robotics on surgical skills was assessed by comparing conventional laparoscopy with the daVinci surgical system in the performance of four training drills. Surgeons completed drills faster with the robotic system. Most importantly, the study found that the playing field between novice and expert laparoscopic surgeons was leveled with use of the robotic system.⁸

Although technical advancements in surgery have brought us robots that provide improved instrument precision and dexterity as well as 3-D imaging in the operating room, new obstacles now exist. For starters, these include the price tag of approximately $1 million for the purchase of a robotic system. Secondly, the absence of tactile feedback (haptics) to the surgeon operating remotely at the console is a drawback. As technology evolves, these issues will need to be addressed. Despite these limitations, the phrase, "this is my assistant, Dr Robot," is not so far off from reality. Although robots will not take the place of surgeons, their role will become more defined in the future. Currently, robots are being used in operating rooms around the country at increasing rates. As an advocate and user of robotic technology, I am excited to be practicing and teaching the art of gynecologic surgery in this day and age. I am also cautious in saying proper studies must be conducted in order to determine the exact role of robotic technology in the practice of minimally invasive surgery. These are exciting times that hold much promise for minimally invasive surgery, particularly in regard to procedure development, patient outcomes, and surgical training.

Arnold P. Advincula, MD
Advisory Board Member

References

1. Mettler L, Ibrahim M, Jonat W. One year of experience working with the aid of a robotic assistant (the voice-controlled optic holder AESOP) in gynecological endoscopic surgery. Hum Reprod. 1998; 13(1O):2748-2750.
2. Degueldre M, Vandromme J, Huong PT, Cadiere GB. Robotically-assisted laparoscopic microsurgical tubal reanastomosis: a feasibility study. Fertil Steril. 2000;74(5): 1020-1023.
3. Molpus KL, Wedergren JS, Carlson MA. Robotically-assisted endoscopic ovarian transposition. JSLS. 2003;7(1):59-62.
4. Diaz-Arrastia C, Jurnalov C, Gomez G, Townsend C Jr. Laparoscopic hysterectomy using a computer-enhanced surgical robot. Surg Endosc. 2002;16(9):1271-1273.
5. Di Marco DS, Chow GK, Gettman MT, Elliott DS. Robotic-assisted laparoscopic sacrocolpopexy for treatment of vaginal vault prolapse. Urology. 2004;63(2):373-376.
6. Chapron C, Laforest L, Ansquer Y, et al. Hysterectomy techniques used for benign pathologies: results of a French multicentre study. Hum Reprod. 1999;14(10):2464-2470.
7. Wattiez A, Soriano D, Cohen SB, et al. The learning curve of total laparoscopic hysterectomy: comparative analysis of 1647 cases. J Am Assoc Gynecol Laparosc. 2002;9(3): 335-345.
8. Sarle R, Tewari A, Shrivastava A, Peabody J, Menon M. Surgical robotics and laparoscopic training drills. J Endourol. 2004;18(1):63-67.

back to top