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

2. Open surgery techniques
Laparoscopic (Keyhole) Surgery
Robotic Surgery

4. 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.

5. 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.

6. 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

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

8. 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

9. 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

10. 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!

11. 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:

12. Evolution of Da Vinci Robot - Standard System

13. da Vinci Robot

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

15. The Da Vinci Robotic System
Surgeon Console
Surgical Cart
Patient Cart

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

17. The Console – Intuitive hand motions

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

19. Endo-Wrist Instruments & telescope

20. Instruments & Operative view

21. 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

22. Training in Robotic Surgery
Simulation Labs

23. 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

24. 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

25. 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!

26. Robotics - FDA

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

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

29. What does RANZCOG say about Robotic Surgery?

30. What does RANZCOG say about Robotic Surgery?

31. 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

32. 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

33. Robotics – Evidence: Sacro-Colpopexy
Courtesy of intuitive

34. 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.

35. 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.

36. Where is Robotic surgery heading?
Single site surgery

37. Where is Robotic surgery heading?
Single site surgery

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

39. Robotics; Future directions
Courtesy of intuitive

40. Robotics; Future directions
Courtesy of intuitive

41. Remember A robot is only as good as its operator.
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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.

42. 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

43. Thank you – Video to follow
References
Image courtesy: Intuitive
Intuitive website &
Uptodate
J Minim Invasive Gynecol May-Jun;20(3): doi: /j.jmig 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 Feb;117(2 Pt 1): doi: /AOG.0b013e f.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