1. Surgery Robotics in Laparoscopy Amanda Mayo University of Toronto MHSc Clinical Engineering (Candidate)

2. Overview Why Robot-Assisted Laparoscopy? Current Applications Current Systems OR set-up Issues and limitations Future possibilities

3. Problems with Conventional Laparoscopy Laparoscopy has revolutionized surgery but has the following limitations: –Limited movement –Reduced from 6 to 4 degrees of freedom –Inability to perform high-precision sutures –Unnatural positions for surgeons –Flat vision (2D)

4. Robot-Assisted Laparoscopy Optical system and robotic arms with highly-specialized instruments connected to a computer- driven mechanism that is controlled by a surgeon Surgeon's hands and fingers direct the surgery and the movements are translated by the computer to precise movement of the microsurgical instruments inside the patient's body

5. Robot-Assisted Laparoscopy: Overcoming Limitations High quality, stable, 3D camera image Tremor elimination Scaled movements (more precise, smaller movements) Robotic instruments have increased degrees of freedom (6 or 7 –4 Motorized Up and Down In and Out Shoulder: Back and Forth Elbow: back and forth –2 Floating Forearm: back and forth Wrist –1 Fixed change in angle Elbow Tilt (+/- 3 degrees)

6. Patient Care Benefits Allow more patients to have minimally invasive surgeries Smaller instruments enable smaller incisions –Less post-operative pain –Faster recovery –Shorter hospital stays –Less blood loss –Smaller scars

7. Current Applications First robot-assisted laparoscopy in 1997 Type and number of robot-assisted surgeries being performed steadily increasing Most studies show feasibility at the cost of increased operating time FDA clearance for: –General Laparoscopy –GERD disease surgery (fundoplication) –Gastric Bypass –Heart valve repair –Prostate removal

8. Current Systems Da Vinci and ZEUS systems FDA approved for surgery Sung and Gill, 2001 compared 2 systems –Da Vinci had shorter operating times and learning curve –Concluded both were effective Currently over 210 Da Vinci systems worldwide (USA, Canada, Japan, Europe, Australia) –61 purchased last year –70% in USA

9. Da Vinci Surgical System Intuitive Surgical Inc., Sunnyvale CA Robotic Cart with 3 or 4 robotic arms –198 x 94 x 97 cm, 544 kg Surgeon manipulates arms using joystick- like handles on control console – 166 x 97 x 158 cm, 227 kg

10. Da Vinci Components Master Controller Robot Cart Control Console

11. More Da Vinci System Features Kinematic (joint movement structure) –Surgeon uses open surgical movements and techniques 7 degrees of Freedom (instruments have an articulating tip) Natural Stereoscopic vision –2 channel endoscope, each channel sampled with its own 3 chip NTSC camera and then displayed on own CRT display –Surgeon immersed in endoscope view Intuitive hand-eye coordination and superior depth perception

12. ZEUS Surgical Robotic System ComputerMotion Inc, Goleta, CA (merged with Intuitive, 2003)

13. ZEUS System Features Over 40 instruments with articulating tips Surgeons hand movements resemble traditional laparoscopic movements Robotic arms mounted on OR table rails –Can adjust table w/o moving robot arms –Arms are compact and weigh < 40 lbs Voice recognition technology Stereovision –One large shutter glass fixed to TV screen polarizes two pictures on the screen to a polarized picture for each eye

14. System Set-up

15. Set-up of System for Surgery Console connected to robotic cart Self-test (verify links and robotic arm function) Robotic arms wrapped in disposable nylon covers –Tips of arms contain microchips that connect surgical instruments Mechanical supports for trocars on the robotic arms fixed Frontal or inclined position of scope (0°-30°) 2D or 3D vision selected Image centered on the monitor after scope insertion White balancing of robotic camera

16. More set-up… Laparoscopic ports are positioned and robotic cart or arms are installed Patient placed in surgical position Robotic arms are connected to optic and operating ports –Accurate placement of ports and robotic cart necessary to avoid collisions between mechanical arms

17. Surgery Robotics Issues Set-up of system is time-consuming –Increased operating time –Time = $ Overall costs are high –Basic system is over $1 million USD –Maintenance and upgrade costs –Training costs –Each instrument ~$1800 Can only be used for 10 procedures Shortage of instruments Cumbersome equipment –Big, bulky cart set-up Disconnection of instruments from robot (rare)

18. In Development… Smaller systems mounted on OR ceiling –Speed up OR set-up time More variety of instruments Re-usable Instruments (> 10 uses) Tele-surgery Expansion of FDA approved procedures –Clinical trial underway to determine appropriate robotic pressure for liver retraction

19. Conclusion The world of surgery is rapidly changing The current generation of robotic systems for laparoscopy have limitations but are an impressive beginning for a new era in surgery As surgeons and engineers continue to work together, future systems will likely evolve into tools that are beyond our current imagination

20. References Intuitive Surgical Inc. Da Vinci website: http://www.intuitivesurgical.com/products/da_vinci.html http://www.intuitivesurgical.com/products/da_vinci.html ComputerMotion Inc. ZEUS website: http://www.computermotion.com/clinicalapplications/roboticprocedures/generalsurgery/ http://www.computermotion.com/clinicalapplications/roboticprocedures/generalsurgery/ Purkayastha S, Athanasiou T, Casula R, Darzi A. Robotic surgery: a review. Hosp Med. 2004 Mar;65(3):153-9. Menkis AH, Kodera K, Kiaii B, Swinamer SA, Rayman R, Boyd WD. Robotic Surgery, the First 100 Cases: Where Do We Go from Here? Heart Surg Forum. 2004 Jan 01;7(1):1-4. Gerhardus D. Robot-assisted surgery: the future is here. J Healthc Manag. 2003 Jul- Aug;48(4):242-51. Ashton RC Jr, Connery CP, Swistel DG, DeRose JJ Jr. Robot-assisted lobectomy. J Thorac Cardiovasc Surg. 2003 Jul;126(1):292-3. Giulianotti PC, Coratti A, Angelini M, Sbrana F, Cecconi S, Balestracci T, Caravaglios G. Robotics in general surgery: personal experience in a large community hospital. Arch Surg. 2003 Jul;138(7):777-84. Wykypiel H, Wetscher GJ, Klaus A, Schmid T, Gadenstaetter M, Bodner J, Bodner E. Robot-assisted laparoscopic partial posterior fundoplication with the DaVinci system: initial experiences and technical aspects. Langenbecks Arch Surg. 2003 Feb;387(11-12):411-6. Ruurda JP, van Vroonhoven TJ, Broeders IA. Robot-assisted surgical systems: a new era in laparoscopic surgery. Ann R Coll Surg Engl. 2002 Jul;84(4):223-6.