1. Robotic surgery - pushing the frontiers in minimally invasive surgery
George Martin
Robotic Surgery Fellow

2. Outline

3. Changes in Training
Old Guy’s Theatre 1822
Old Guy’s Theatre (1821)

4. Doctor in the House

5. Laparoscopic surgery – why?
Open radical nephrectomy
Laparoscopic nephrectomy

6. Open surgery
See one
Do one
Teach one

7. Open ≠ Laparoscopic 2-D Image Specific skills required
Minimal tactile feedback
Remote image
Distance & lever effect
Specific skills required

8. Dry Lab

9. Why robotics? Minimally-invasive surgery benefits patients
New technology essential
Information systems
Imaging systems
Mechatronics
Insert shortened wound video

10. Karol Capek, 1921 “robota” = forced work
Robots help humans with daily work but eventually turn on their masters and attempt world domination
Karol Capek, 1921
“robota” = forced work

11. Terminology & Definitions
Robot
“computer-controlled manipulator with artificial sensing…preprogrammed to control tools to perform complex tasks”
Automation
Robotic vs robotic-assisted
Truly autonomous Vs
Responds to instruction or control interface
Surgical “robots” don’t fulfill criteria

12. 1. Laparoscope manipulators 2. Master-slave systems

13. 1. Laparoscope manipulators
EndoAssist™
AESOP®

14. 2. Master-slave systems Stanford Research Institute (SRI) –
SRI Concept and patent drawing. Stamford Research Institute / US Defence and IBM were all working on robotic programs, and they all amalgamated to work on robotic surgery.
Stanford Research Institute (SRI) –
Green Telepresence System

15. 2. Master-slave systems Zeus™ surgical system
Computer Motion/Intuitive Surgical
da Vinci® surgical system
Intuitive Surgical

16. 2. Master-slave systems Zeus™ surgical system
Computer Motion/Intuitive Surgical
da Vinci® surgical system
Intuitive Surgical

17. Leonardo da Vinci – Father of Robotics (1452–1519)
Sketched plans for a humanoid robot
Mechanical knight now known as Leonardo's robot
Anatomy probably based on Vitruvian Man
Vitruvian man – Vitruvius was an architect. Ideal proportions of man
He drew the robot around 1495

18. What is Robotic Surgery?
da Vinci Surgical System®
Advanced laparoscopic surgery device
Patient-side robotic cart
Surgeon console
Vision cart

19. Laparoscopic access

20. What is Robotic Surgery?

21. Technical considerations
Advantages
Disadvantages
EndoWrist™ vastly superior to conventional lap instruments
3D vision and 10x magnification
Ergonomics
Expensive to buy
$3.5 million
Expensive to run
(monopoly)
Excellent assistant required

22. Conventional laparoscopic suturing
Robot-assisted suturing

23. da Vinci® Surgical System U.S. Installed Base 1999 – 2009
2009-through Q3 close
2005
Alaska
2007
2001
2008
2003
2002
2004
2006
Hawaii
2000
1999
Over the last five years the installed base of da Vinci Surgical Systems has grown significantly.

25. Prostate cancer Most common male cancer 20,000 new cases per year
3,500 deaths

26. The goals of radical prostatectomy
Cancer control
Continence
Potency
“The trifecta”
Nerve-sparing dissection
Immunohistochemical studies of the NVB.
Costello, Murphy BJUi 2010 in press

27. Open radical prostatectomy
Gold standard

28. Open radical prostatectomy
Gold standard
Is it MORBID??
Mortality <1%
Blood transfusion 20-30%
Complications 9-30%
Hospital stay 6.4 days
Incontinence <10%
Erectile dysfunction 14-44%
Judge et al. BJUi 2007
Catalona et al. J Urol 2004
Walsh et al. Urology 2000
Graefen et al Eur Urol 2006

29. Robotic prostatectomy
May not play in PPT – may need to do HTML link to the AVI file

30. Why should robotic-assisted be better?
Minimally-invasive
Less pain etc
Robot-specific
See better
Cut better
Easier than pure laparoscopy
It’s a robot – it must be better!!
Improved outcomes?

31. Eur Urol 2009; 55(6):

32. So what’s next??

33. Current robotic simulators 1
dV Trainer
Mimic Technologies

34. Current robotic simulators 1

35. What next? Dual console system Simulation Image-guided surgery
Roof-mounted robotic arms
Single-port robotic surgery
Multispeciality
Competition (please)

36. Single port surgery Through umbilicus or small single incision
“A triumph of technical ability over common sense”
Through umbilicus or small single incision
Technically challenging
Inadequate optics and instrumentation
Robotic platforms required

37. Conclusions Minimally-invasive surgery is evolving rapidly
Robotic platforms will enable further advance
Increasing integration with a digital environment:
Imaging
Information systems
Simulation/Virtual reality
Almost limitless potential!

38. Thank you