Surgery Robotics in Laparoscopy

Amanda Mayo University of Toronto MHSc Clinical Engineering (Candidate)

Overview

• Why Robot-Assisted Laparoscopy?

• Current Applications • Current Systems • OR set-up • Issues and limitations • Future possibilities

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)

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

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)

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

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

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

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

Da Vinci Components

Master Controller Control Console Robot Cart

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

ZEUS Surgical Robotic System

• ComputerMotion Inc, Goleta, CA (merged with Intuitive, 2003)

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

System Set-up

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

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

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)

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

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

References

• • • • • • • • • Intuitive Surgical Inc. Da Vinci website: http://www.intuitivesurgical.com/products/da_vinci.html

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