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Is robotic cholecystectomy superior than laparoscopic

Khaled hussien gad Ain Shams university (Cairo-Egypt)

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Abstract

This review article confronted to the new technology on the occasion of the twentieth anniversary in the great development of general surgery. After great success of laparoscopic cholecystectomy during the last century , robotic cholecystectomy is rising now undoubtedly. Robotic surgery still in the beginning . We try to compare the safety of both technique separately.

Background

On September 12 th 1985, Prof. Erich Muhe of Boeblingen, Germany, carried out the first laparoscopic cholecystectomy. Later he modified his technique and operated through a trocar sleeve. Finally , he designed an ( open laparoscope) with a circular light .By March 1987 , Muhe had conducted 97 endoscopic gallbladder removals. After reporting that he had performed the first laparoscopic cholecystectomy in the Germany Surgical Society meeting in 1986, he was severely criticized (Litynski , 1998).

Since 1921when Czech playwright Karl Capek introduced the notion and coined the term robot in his play Rossom’s Universal Robots, robots have taken on increasingly more importance both in imagination and reality (Stava RM 2002). Robot, taken from the Czech robota, meaning forced labour, has evolved in meaning from dumb machines that perform menial, repetitive tasks to the highly intelligent anthropomorphic robots of popular culture. Although today’s robots are still unintelligent machines, great strides have been made in expanding their utility. Today robots are used to perform highly specific, highly precise, and dangerous tasks in industry and research previously not possible with a human work force. Robots are routinely used to manufacture microprocessors used in computers, explore the deep sea, and work in hazardous environment to name a few. Robotics, however, has been slow to enter the field of medicine.

The origin of surgical robotic is rooted in the strength and weaknesses of its predecessors. Minimally invasive surgery began in 1987 with the first laparoscopic cholecystectomy. Since then, the list of procedures performed laparoscopically has grown at a pace consistent with improvements in technology and the technical skill of surgeons( Jones SB and Jones DB 2001).

Robots were first used in surgery in the mid-1990s. The first food and drug administration- approved AESOP robot , held the laparoscopic camera and resbond to voice command that moves the tip of the instruments in a natural direction ( Sakier and Wang 1994).The advantages of minimally invasive surgery are very popular among surgeons, patients, and insurance companies. Incisions are smaller, the risk of infection is less, hospital stays are shorter, if necessary at all, and convalescence is significantly reduced. Many studies have shown that laparoscopic procedures result in decreased hospital stays, a quicker return to the workforce, decreased pain, better cosmesis, and better postoperative immune function (Kim VB et al 2002 ). As attractive as minimally invasive surgery is, there are several limitations. Some of the more prominent limitations involve the technical and mechanical nature of the equipment. Inherent in current laparoscopic equipment is a loss of haptic feedback (force and tactile), natural hand-eye coordination, and dexterity. Moving the laparoscopic instruments while watching a 2-dimensional video monitor is somewhat counterintuitive. One must move the instrument in the opposite direction from the desired target on the monitor to interact with the site of interest. Hand-eye coordination is therefore compromised. Some refer to this as the fulcrum effect ( Stava RM ,et al 2001 ). Current instruments have restricted degrees of motion; most have 4 degrees of motion, whereas the human wrist and hand have 7 degrees of motion. There is also a decreased sense of touch that makes tissue manipulation more heavily dependent on visualization. Finally, physiologic tremors in the surgeon are readily transmitted through the length of rigid instruments. These limitations make more delicate dissections and anastomoses difficult if not impossible (Prasad et al 2001). The motivation to develop surgical robots is rooted in the desire to overcome the limitations of current laparoscopic technologies and to expand the benefits of minimally invasive surgery.

Advatages of Robotic Assisted Surgery:

The advantages of these systems are many because they overcome many of the obstacles of laparoscopic surgery. They increase dexterity, hand-eye coordination and an ergonomic position, and improve visualization . In addition, these systems make surgeries that were technically difficult or unfeasible previously, now possible. These robotic systems enhance dexterity in several ways. Instruments with increased degrees of freedom greatly enhance the surgeon’s ability to manipulate instruments and thus the tissues. These systems are designed so that the surgeons’ tremor can be compensated on the end-effector motion through appropriate hardware and software filters. In transformed into micromotions inside the patient (Kim VB , et al 2002). Another important advantage is the restoration of proper hand-eye coordination and an ergonomic position. These robotic systems eliminate the fulcrum effect, making instrument manipulation more intuitive. With the surgeon sitting at a remote, ergonomically designed workstation, current systems also eliminate the need to twist and turn in awkward positions to move the instruments and visualize the monitor.

By most accounts, the enhanced vision afforded by these systems is remarkable. The 3-dimensional view with depth perception is a marked improvement over the conventional laparoscopic camera views. Also to one’s advantage is the surgeon’s ability to directly control a stable visual field with increased magnification and maneuverability. All of this creates images with increased resolution that, combined with the increased degrees of freedom and enhanced dexterity, greatly enhances the surgeon’s ability to identify and dissect natomic structures as well as to construct microanastomoses.

Disadvatages of robotic- assisted system:

There are several disadvantages to these systems. First of all, robotic surgery is a new technology and its uses and efficacy have not yet been well established .To date, mostly studies of feasibility have been conducted, and almost no long-term follow up studies have been performed. Many procedures will also have to be redesigned to optimize the use of robotic arms and increase efficiency. However, time will most likely remedy these disadvantages.

Another disadvantage of these systems is their cost. With a price tag of a million dollars, their cost is nearly prohibitive. Whether the price of these systems will fall or rise is a matter of conjecture. Some believe that with improvements in technology and as more experience is gained with robotic systems, the price will fall (Kim VB ,et al 2002). Others believe that improvements in technology, such as haptics, increased processor speeds, and more complex and capable software will increase the cost of these systems. Also at issue is the problem of upgrading systems; how much will hospitals and healthcare organizations have to spend on upgrades and how often? In any case, many believe that to justify the purchase of these systems they must gain widespread multidisciplinary use ( Stava R M , et al 2001).

Another disadvantage is the size of these systems. Both systems have relatively large footprints and relatively cumbersome robotic arms. This is an important disadvantage in today’s already crowded-operating rooms( Stava R M , et al 2001). It may be difficult for both the surgical team and the robot to fit into the operating room. Some suggest that miniaturizing the robotic arms and instruments will address the problems associated with their current size. Others believe that larger operating suites with multiple booms and wall mountings will be needed to accommodate the extra space requirements of robotic surgical systems. The cost of making room for these robots and the cost of the robots themselves make them an especially expensive technology.

One of the potential disadvantages identified is a lack of compatible instruments and equipment. Lack of certain instruments increases reliance on tableside assistants to perform part of the surgery (Kim VB ,et al 2002). This, however, is a transient disadvantage because new technologies have and will develop to address these shortcomings.

Most of the disadvantages identified will be remedied with time and improvements in technology. Only time will tell if the use of these systems justifies their cost. If the cost of these systems remains high and they do not reduce the cost of routine procedures, it is unlikely that there will be a robot in every operating room and thus unlikely that they will be used for routine surgeries.

Results of robotic cholecystectomy:

David W et al in 2004 after a retrospective study from October 2002 to July 2003 of all robotic assisted cholecystectomy (19 cases) found that 16 were completed successfully . A mechanical problem with the robot in 3 consecutive patients ; however all procedures were competed laparoscopically.There were no complication and no converstions to open procedure .They conclude that robotic surgery offers many potential advantages , including surgeon comfort , elimination of surgeon tremors , improved imaging , and increased degrees of freedom of the operative instruments, compared with conventional laparoscopic surgery(David w et al 2004).

Tamas J et al 2006 showed after Forty-eight of the 51 procedures (94%) were completed robotically. We did not experience any significant complications directly related to robotics surgery. . The mean ± SD operating time was 77 ± 22.3 min. The mean setup time for robotics (from incision until robot was in place, including draping the robot) was 24 ± 8.8 min. However, the setup time significantly improved as we gained more experience: from 30.6 ± 10.7 min (first 16 cases) to 18.3 ± 4.0 min (cases 33–48). The mean robotic time was 34 ± 16.1 min. We observed no significant improvement in robotic procedure time (Tamas J et al 2006).

Breitenstein et al 2008 showed after A prospective case-matched study was conducted on 50 consecutive patients, who underwent robotic-assisted cholecystectomy (Da Vinci Robot, Intuitive Surgical)between December 2004 and February 2006. These patients were matched 1:1 to 50 patients with conventional laparoscopic cholecystectomy, according to age, gender, American Society of Anesthesiologists score, histology, and surgical experience. Endpoints were complications after surgery (mean follow-up of 12.3 months [SD 1.2]), conversion rates, operative time, and hospital costs (ClinicalTrial.gov ID: NCT00562900).

No minor, but 1 major complication occurred in each group (2%). No conversion to open surgery was needed in either group. Operation time (skin-to-skin, 55 minutes vs. 50 minutes, P < 0.85) and hospital stay (2.6 days vs. 2.8 days) were similar. Overall hospital costs were significantly higher for robotic-assisted cholecystectomy $7985.4 (SD 1760.9) versus $6255.3 (SD 1956.4), P < 0.001, with a raw difference of $1730.1(95% CI 991.4-2468.7) and a difference adjusted for confounders of $1606.4 (95% CI 1076.7-2136.2). This difference was mainly related to the amortization and consumables of the robotic system (Breitenstein et al 2008) Gamal A. Khairy et al (2004) showed that robotic surgery is the surgery of the future , feasible and safe .

Discussion:

Prof. Erich Muhe After reporting that he had performed the first laparoscopic cholecystectomy in the Germany Surgical Society meeting in 1986, he was severely criticized (Litynski , 1998). Robots were first used in surgery in the mid-1990s. The first food and drug administration- approved AESOP robot , held the laparoscopic camera and resbond to voice command that moves the tip of the instruments in a natural direction ( Sakier and Wang 1994).Usually there great resistance to the new era in surgery .There are several advantages of robotic surgery over conventional laparoscopic cholecystectomy , but there also disadvantages . Robotic surgery is as safe as conventional laparoscopic surgery( Breitenstein et al 2008).David W et al conclude that robotic surgery offers many potential advantages , including surgeon comfort , elimination of surgeon tremors , improved conventional laparoscopic surgery(David w et al 2004).


Conclusion:

Robotic surgery offers many potential advantages , including surgeon comfort , elimination of surgeon tremors , improved imaging , and increased degrees of freedom of the operative instruments , compared with conventional laparoscopic surgery. The safety of both robotic and conventional laparoscopic cholecystectomy are nearly the same. Most of the disadvantages of the robotic surgery identified will be remedied with time and improvements in technology. Only time will tell if the use of these systems justifies their cost. If the cost of these systems remains high and they do not reduce the cost of routine procedures, it is unlikely that there will be a robot in every operating room and thus unlikely that they will be used for routine surgeries.
References:
Litynski G S. Erich Muhe and the rejection of laparoscopic cholecystectomy (1985): A Surgeon ahead of his time. JSLS 1998 ; 2:341-6.
Stava R M . Surgical robotics: The early chronicles : a personal historical prospective. Surg Laparosc Endosc percutan tech . 2002 ; 12: 6 – 16 [PubMed].
Anthony R , Lanfranco , Bas et al : Robotic surgery A current Perspective. Ann Surgery. 2004 January.
Jones S B , Jones D B . Surgical aspect and future developments in the laparoscopy. Anthiol Clinic North Am . 2001 ; 19 : 107- 124.
Kim V B , Chapman W H , Albert R J , et al : Early experience with telemanipulative robot-assisted laparoscopic cholecystectomy using Da Vinici system. Surg laparosc Endosc percut 2002 ; 12:34-40.
Prasad S M , Ducko CT , Stephenson E R et al : Prospective clinical trial of robotically assisted endoscopic coronary grafting with 1 year follow up . Ann Surg . 2001 ; 233: 725-732.
Stava R M, Bower Sox J C Mack M, et al: Robotic surgery ; state of art and future trends. Contemp Surg. 2001 ; 57 : 489-499.
David W. Miller, Richard t. Schlinkert , Denise K Schlinkert : Robotic assisted laparoscopic cholecystectomy : Initial Mayo Clinic Scott Experience . Mayo clinic proc . September 2004 ; 79 (9) ; 1132-1136.
Sakier J M , Wang Y : Robotically assisted laparoscopic surgery: from concept to development. Surg Endosc . 1994 ; 8: 63-66.
Tamas J .Vidovszky , William Smith , Jaganmath ghosh and Mohamed R Ali : Journal of surgical Research volume 136 . Issue2 , December 2006 Pages 172-178.
Breitenstien s , et al : Robotic-assisted versus Laparoscopic cholecyctectomy. Outcome and cost analysis of a case matched control study . Ann Surg. 2008 Jun ; 247 (6) : 987-993.
Gamal A .Khairy et al : A new era in laparoscopic surgery Evolution of robotic-assisted Laparoscopic procedures. Depatment of surgery, college of medicine and King Khalid University Hospital .22nd November 2004.

 

 

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