Small robot with big benefits for the OR

Robotic technology is increasingly being used worldwide for a wide range of medical applications – from treating cancer (CyberKnife), minimally invasive brain surgery (Renaissance) and laparoscopic prostatectomy (DaVinci); to unicondylar knee replacement (NavioPFS) and even hair transplantation (ARTAS). Accuracy and repeatability are some of the benefits cited for the use of robotics to perform procedures in the operating room (OR). However, the application of robotics in surgery has not been without its challenges, as Maximilian Krinninger, product manager, Trumpf Medical Systems GmbH, acknowledges: “The introduction of robotics into the OR began around the early 90s. Although the use of robotics in theatre offered a great deal of possibilities and opportunities, robots did not always deliver on these promises in the very early days. Surgeons became frustrated, as insufficient thought had been given to the integration of these devices in the OR,” he commented. “The systems were too big, too fast, too heavy or too dangerous. In particular, the perception of robotics was affected by problems arising from the use of a robot used for drilling bone, during hip replacement. In fact, the harm was caused by the positioning of the patients and not the robot device itself, but, for a long period, surgeons did not want to engage with the possibilities of robotics as a result of negative reports,” he continued. He added that, over the last ten years, interest in robotics has grown significantly due to the success of Intuitive Surgical’s DaVinci robot, which is now used for laparoscopic procedures across the globe, including various centres in the UK. “The success of the DaVinci has opened up new opportunities for the application of robotics in the OR – with a variety of robotic solutions emerging. Today, surgeons are recognising and understanding their limitations, and how they can be overcome with a new generation of systems.” Oliver Law, managing director, Trumpf Medical Systems UK, commented that, although there are areas where the UK pioneers, it has traditionally been conservative in its adoption of healthcare innovation, lagging behind other European countries. Nevertheless, there has been some initial uptake of robotics in the UK. “One of the problems, in the past, has been that some systems have proven to be cumbersome or difficult to use. Talking to surgeons across the UK, there is some scepticism about the use of robotics. They comment that feel and touch are extremely important to them and they are concerned that robotic systems may take this away. Some surgeons also take the view that ‘I am a good surgeon – I do not need robotics’ – there is a certain stigma attached to using the technology. These are some of the views that need to be overcome in order to increase adoption of robotic systems in the OR,” he said.

Assisting laparoscopic surgery

However, there is an additional field of medical robotics, in which the technology fulfills the function of ‘an assistant’ – for example, to help achieve stable endoscopic views of the surgical field during lengthy procedures. Laparoscopic surgeons are already experienced at adapting to the loss of ‘touch and feel’, inherent in minimally invasive surgery. Moreover, robotic endoscope positioning systems do not require a major change in the way laparoscopic surgeons are used to working – it is a relatively easy transition, requiring just a few days of training. The potential benefits are significant. Such ‘surgical assistants’ can be used to tackle the problem of human fatigue, while lending an ‘extra pair of hands’ to allow surgery to be carried out by a smaller team. Laparoscopic surgery offers the patient many benefits – including reduced scarring, faster recovery, less pain and reduced risk of surgical site infection. However, it also presents challenges for the surgeon. While viewing a monitor, the surgeon has to hold the instruments exactly in place and guide them within the patient’s body. The first challenge is that the image on the screen is only twodimensional; however, the direction along which the instruments work is seldom congruent to the viewing direction. Additionally, the instruments can be moved to only a limited extent, within a restricted field of movement. Since the surgeon must use both hands to guide the instrument, an assistant surgeon is called upon to hold and guide the endoscopic camera. That assistant must constantly try to predict where the surgeon will want to look next – and must respond quickly and correctly to the surgeon’s instructions. It is often necessary to maintain a fixed and static position for a very long time. This strenuous and monotonous task quickly leads to fatigue. In addition, it is virtually impossible to keep the endoscope lens from making contact with tissue. This makes it necessary to clean the lens, which necessitates time-consuming new positioning of the endoscope.