Robotics Introduction to Gynaecological Robotic surgery Laparoscopy Abdominal Vaginal Dr Amani Harris Leonardo da Vinci 1452-1519 self-portrait (circa 1512 to 1515)

Open surgery techniques Laparoscopic (Keyhole) Surgery Robotic Surgery

What is Robotic Assisted Surgery? Robot is a newer generation surgical tool to assist surgeons in performing surgery. It is not changing the basics of Surgery. Robotic assisted surgery is not something new, this idea has been floating for decades.

Robotic Knight – 15th Century Model of a robot based on drawings by Leonardo da Vinci. On display in Berlin Museum. According to the manufacturer, the da Vinci System is called “da Vinci” in part because Leonardo da Vinci invented the first robot. The artist Leonardo also used anatomical accuracy and three-dimensional details to bring his works to life.

Important timelines: 1985 PUMA 560 system: placing a needle for brain biopsy using CT guidance 1988 PROBOT: Prostrate surgery 1992 ROBODOC: used to assist hip replacement 1997 da Vinci Robot: Tubal re-anastmosis 1999 Robotic Assisted Coronary Bypass 2001 Tele-Surgery: Cholecystectomy, Surgeon in New York; Patient at Strasburg 2005 da Vinci Robotic Assisted Hysterectomy

What is a Surgical Robotic? Passive Autonomous Assistive Active Actively control the instruments ( master – slave manipulators) Eg: Da Vinci, Aesop,

Currently Available Robotics AESOP: robotic camera holder Da Vinci Robot: integrated immersive system the robotic camera holder (AESOP) holds and controls the laparoscopic camera. Of note, it is being phased out. AESOP was initially introduced with surgeon-operated foot switch or hand control and was later modified to respond to voice commands with a 23-word vocabulary

Active Robots - terminology Immersive Haptics Tele operative Tele presence Telementoring Telestration Haptics – The lack of haptics (ie, tactile feedback) is a limitation of robotic surgery. The surgeon cannot actually feel the resistance of the tissue as the instrument meets or manipulates the tissue, but accommodates for this by using visual cues and knowledge of anatomy and surgical planes based upon previous surgical experience and study of anatomy.   Telepresence surgery implies: an expansion of telerobotics which allows a surgeon at remote locations to receive images and manipulate a telerobot to perform an operation without ever encountering the patient. Telementoring: 2 way conversation and video giving surgeons the oppurtunity to be guided through a procedure by a more experienced surgeon from affar. This has a role in overcoming the “learning curve” associated with robotics. Telestration: Freehand drawing with the 3D video display. Important for surgeons and trainees. Useful for : intra-operative communication, anatomical annotation, defining virtual fixtures pictorially, and education

Active Robots – da Vinci Surgical System Utilizes advanced technology to assist surgeons with operations Decreases the need for open Surgery Does NOT act on its own All movements are controlled by the surgeon System has a 3D high definition vision – can be magnified up to 10 times Instruments have mechanical wrist that bend and rotate to mimic the movements of the human wrist. ? Improves patient outcomes Makes a difficult case easier or even yet an impossible case do-able. The Robot Does not: Teach Anatomy Teach Surgical principles Teach Respect for tissue planes Transform the surgeon or replace the surgeon!

Evolution of Da Vinci Robot Evolution of Surgery Evolution of Da Vinci Robot 1995 Intuitive Surgical was founded 1999, The first da Vinci System was introduced to market 2000 US FDA cleared da Vinci for laparoscopic surgery 2003 first major upgrade - 4th instrument arm 2006 da Vinci S System In the late 1980s DARPA (Defense Advanced Research Projects Agency) funded several of these institutions to research the possibility of a remote surgery program targeted toward battlefield triage. Similar to the robotic drones (planes) available today and used in foreign conflicts, the idea was to replace human medics with robots and minimize human casualties. It turns out the idea of a robotic medic was flawed due to its vulnerability to tracking devices and changing policies about how and where wounded soldiers are treated. However, as a result of the funding from DARPA, significant advancements were made toward telepresence at many institutions. For example, SRI was responsible for developing a "telepresence surgery system." The preliminary schematic drawing of this system eventually influenced the da Vinci design. Other notable achievements were the IBM-developed remote center technology and the MIT-developed cable-driven technology for low-friction manipulators which are also used in today’s da Vinci System. - See more at: http://www.intuitivesurgical.com/company/history/is_born.html#sthash.AIUF7xXI.dpuf

Evolution of Da Vinci Robot - Standard System

da Vinci Robot

Evolution of Da Vinci Robot 2006 ‘S’ system 2009 da Vinci ‘Si’ system

The Da Vinci Robotic System Surgeon Console Surgical Cart Patient Cart

The Console Filtered tremors 7degrees of freedom Multi-task 3-D Vision

The Console – Intuitive hand motions

Patient’s cart -Robotic surgical arms As large an OT theatre as possible is needed, as the robot is quite bulky

Endo-Wrist Instruments & telescope

Instruments & Operative view

Advantages Disadvantages Robotic Surgery Advantages Disadvantages Ergonomic 3-D Vision Filtered tremors Improved dexterity; 7 degrees of freedom Less fatigue Allows performing complex procedure Lack of tactile feedback Can’t change operating table position once arms are docked to patient Set up time Cost Capital cost Maintenance Disposables

Training in Robotic Surgery Simulation Labs

Training 20 -40 hours on the simulator Achieve scores on >85-90% on all tasks Dry lab – 1 full day session Docking on dummies Types of docking Wet Lab – Pig lab 1 full day session Operate on anesthetized pigs Port placement and docking Perform surgeries such as ureterolysis, Nepherectomy, etc

Credentialing Perform 3 major surgeries supervised by a recognized Proctor Some hospitals require you to do 5 cases Perform a minimum of 20 cases per year to maintain your accreditation You will be listed as a robotic surgeon on the global da Vinci website You can be a Proctor once you have completed 50 cases

Issues with Training and accreditation Access is an issue Trainers are still learning What is the safest and best way to learn? What is the learning curve? How many cases required per year to maintain proficiency? At least 20 per year…1 per fortnight!

Robotics - FDA

What does Intuitive say about the da Vinci Robotic Surgical experience?

What does Intuitive say about the da Vinci Robotic Surgical experience?

What does RANZCOG say about Robotic Surgery?

What does RANZCOG say about Robotic Surgery?

What does RCOG say about Robotic Surgery? Another clear advantage of robotic surgery is that fewer errors are made than with straight-stick surgery says the review. A recent review of hysterectomies compared operations conducted by robotic surgery and laparoscopic surgery. The results showed that robotic surgery was quicker, reduced the hospital stay of the patient and resulted in less blood loss

What does ACOG say about Robotic Surgery? The outcome of any surgery is directly associated with the surgeon’s skill. Highly skilled surgeons attain expertise through years of training and experience. Studies show there is a learning curve with new surgical technologies, during which there is an increased complication rate. Robotic hysterectomy generally provides women with a shorter hospitalization, less discomfort, and a faster return to full recovery compared with the traditional total abdominal hysterectomy (TAH) which requires a large incision. However, both vaginal and laparoscopic approaches also require fewer days of hospitalization

Robotics – Evidence: Sacro-Colpopexy Courtesy of intuitive

Robotics – Evidence: Myomectomy 575 cases RAM (15%) LM (16%) AM (68%) Weight 223gm 96.6gms 263gms Blood loss 150mls 100mls 200mls Time 181 mins 155 mins 126 mins Stay in hospital (days) 1 3 Conclusion: Robotic-assisted myomectomy is associated with decreased blood loss and length of hospital stay compared with traditional laparoscopy and to open myomectomy. Robotic technology could improve the utilization of the laparoscopic approach for the surgical management of symptomatic myomas.

Robotics – Evidence: Myomectomy Conclusion: RLM has significant short-term benefits compared with AM and no benefits compared with LM. Long-term benefits such as recurrence, fertility, and obstetric outcomes remain uncertain.

Where is Robotic surgery heading? Single site surgery

Where is Robotic surgery heading? Single site surgery

Robotics; Future directions Augmented Reality Real time data fusion Courtesy: CBYON Courtesy of Intuitive

Robotics; Future directions Courtesy of intuitive

Robotics; Future directions Courtesy of intuitive

Remember A robot is only as good as its operator. ``````` A robot is only as good as its operator. If you are not a good surgeon, Robotic surgery is not going to make you into one. Similarly, Robot is not going to make you a fantastic laparoscopic surgeon.

Remember One still needs to understand the principles of Laparoscopy. Robotic assisted surgery is not here to replace Laparoscopic surgery. Robotic assisted surgery has its place with complex surgeries Complex hysterectomies Grade 4 endometriosis Sarco-colpopexy

Thank you – Video to follow References Image courtesy: Intuitive Intuitive website & http://www.davincisurgery.com Uptodate J Minim Invasive Gynecol. 2013 May-Jun;20(3):335-45. doi: 10.1016/j.jmig.2012.12.010. Epub 2013 Feb 27. Robotic- assisted laparoscopic vs abdominal and laparoscopic myomectomy: systematic review and meta-analysis.Pundir J1, Pundir V, Walavalkar R, Omanwa K, Lancaster G, Kayani S. Obstet Gynecol. 2011 Feb;117(2 Pt 1):256-65. doi: 10.1097/AOG.0b013e318207854f.Robotic-assisted, laparoscopic, and abdominal myomectomy: a comparison of surgical outcomes.Barakat EE1, Bedaiwy MA, Zimberg S, Nutter B, Nosseir M, Falcone T. RANZCOG RCOG ACOG