Robotic Surgery

One of the newest developments for minimally invasive operations  in General Surgery is the application of robotic technology to routine abdominal and pelvic surgery. The DaVinci Surgical Robotic System developed by Intuitive Surgical  is the leader in the field. This robotic system is exactly what it says – intuitive. It is a well designed system that is extremely easy for the surgeon to use and has many benefits for the surgeon and the patient.

The way it works is this: As usual, the patient is given a general anesthetic and prepped and draped in the typical manner. The abdomen is filled with carbon dioxide through a tiny nick in the skin through a specially designed safety needle. A 1.2 centimeter incision is made and a thin plastic cylinder called a trocar is gently pushed through the abdominal muscle and into the abdomen with an easy back-and-forth twist. A miniature camera lens is placed through the trocar and into the abdomen to look around, the image highly magnified on a TV screen hanging from the ceiling on a movable arm. Two, three, or four more trocars are placed through additional tiny incisions, the number depending upon the number of robotic arms needed for the operation at hand. A trocar is placed for a bedside assistant to use as well.

The robot is then rolled to the table and docked, each arm attached to a trocar and then loaded with the surgeon’s choice of instruments for the case.

The surgeon then leaves the table and and takes a seat at a nearby console from which he will perform the operation. He slides his seat up to the “cockpit,” places his forearms on a horizontal rest, places the thumb and third finger of each hand into the hand controls, places his feet in position to run four different foot pedals to adjust the camera and robot arms and energy sources for the operation, and places his face into a forehead console that contains a large screen where the camera image is magnified in 3-D.

Every movement the surgeon makes with the fingers of each hand is transmitted directly to the instruments locked in the arms of the robot. The movements are absolutely precise. The instruments are especially designed with “wrists” that make them work like tiny little hands inside the abdomen, making it possible for incredible rotation, extension, and flexion of the working end of the instrument; in fact, it acts almost exactly like the surgeons regular wrist and hand. The robot sensors indicate the exact center of the trocars at the level of the muscle in the abdominal wall so that all robotic arm movements use that point as the movement fulcrum; there is thus no tension of any sort placed on the entry point in the muscle. It is as if the surgeon climbed inside in miniature to do his work.

The surgeon can thus do the operation inside within a smaller space and without pushing and pulling on the abdominal wall muscle. The magnification is tremendous, and everyone in the room can see the operation in real time on various monitors hanging around the room as it is performed, making it easy to anticipate the surgeon’s needs. The assistant at the table helps by passing sutures and needed materials inside to the “hands” of the working instruments as requested by the surgeon, and assists with retraction, irrigation, and suction as needed. If a surgeon is teaching, he can “write” on one of the TV touch screens in the room with his finger-tip, showing the surgeon at the console, who can see the writing in his own viewfinder, exactly where to cut, sew, retract, or place an implant. The technology is so advanced, in fact, that one could sit at a console in the comfort of their living room here in Iowa and operate on a patient anywhere in the country!

Since everything is highly magnified, blood loss is reduced to nearly zero. Every tiny little blood vessel is easily seen and coagulated before even a drop of blood can be lost. The instruments make it possible to sew with ease and get into places where one cannot normally work using regular laparoscopic instruments while operating at the bedside. Anatomical landmarks are easily located and sensitive structures avoided. As a result of all of these improvements, the patient awakens with even less discomfort than they would have with regular laproscopy (minimally invasive surgery). Their hospital stay is frequently shortened as well.

As for the surgeon, he/she can work while sitting comfortably and without stress and strain to the neck, back, and shoulders; they can see better and work efficiently. At the end of the case they are not sore and exhausted.

So with robotic surgery, everyone wins. The operation is performed with ease for the surgeon, the patient feels better and goes home earlier, there is less need for transfusion, return to work and regular life is facilitated, the surgical team can see and help more productively, and costs are reduced for the insurance carrier.

There is, as always, one downside. The technology is expensive and is a big investment for the medical center. Nonetheless, the overall process likely results in less cost in the overall system. Even newer technology coming down the pike will further enhance our ability to perform operations with even higher precision. It makes it a great time to be a surgeon, as this technological revolution is a fascinating challenge for us and is exactly the sort of development that gives us renewed interest, excitement, and pleasure in our work every day. For me, it has always been the process of finding and then learning and applying better methods in surgery and medicine that has kept me interested every day—-the constant challenge of it all from a professional and intellectual standpoint. Add in the improved experience and outcomes for my patients, and it makes for a really happy combination for all of us.

I’ve used the DaVinci robotic surgical system for a wide variety of cases, including Fundoplication for Reflux Disease, Gall Bladder removal, Colon and Rectal surgery for both cancer and benign colon diseases, Hernia Repairs, Bladder Suspensions for Poor Bladder Control, Hysterectomy and Ovarian procedures, Vaginal Suspension for Prolapse, Removal of Adhesions, Lymph Node Dissections for cancer, and others. The Urologists in our group are using it for Radical Prostatectomy for Prostate Cancer as well as major kidney operations and other procedures for the ureter and bladder. Other surgeons around the country are likewise applying robotics in their minimally invasive surgical cases, and like us, sometimes performing operations that we couldn’t do using minimally invasive techniques before!

Robotics is changing the world of surgery for the better in a myriad of ways. In my twenty year career I’ve gone from doing everything with a big incision and long hospital stays  to space-age outpatient major surgery, and in some cases now even incision-less surgery! Who could have imagined such things??!! I’m reminded of my childhood in the 60’s watching “The Jetsons”  cartoon and musing to myself how cool it would be if we actually HAD  robots and magical  artificial brains and invisible waves flying through the air that could make things around us move and do things and make our lives so much better. Well, it’s all arrived, that’s for sure, and nothing will ever be the same again. This career of mine has certainly been a fun, interesting, and yes – even magical – journey. 🙂

David D. Coster, M.D., FACS