[dropcap]In[/dropcap] 1983, the “Arthrobot” made its mark on the medical community by becoming the world’s first robot to assist in surgery. Developed by a team of physicians and engineers in Vancouver, British Columbia, the Arthrobot introduced robotic technologies into the surgical suite.
In 2000, another milestone was made when the da Vinci Surgical System became the first robotic platform to be approved by the Food and Drug Administration for general laparoscopic surgery.
Today, robotic technology continues its forward progress and offers surgeons sophistication and precision in performing a variety of minimally invasive procedures.
Dr. Michael S. Cookson is an uro-oncologist at the Stephenson Cancer Center and the director of robotics surgery at the OU Medical Center in Oklahoma City. He also serves as professor and chairman of the department of urology at the University of Oklahoma College of Medicine.
[pullquote]For prostate cancer, about 85 percent of all surgeries (radical prostatectomies) in the United States this year will be performed robotically.”[/pullquote]“The advantages of robotic surgery include smaller incisions with reduced pain (so less pain medication, too), a shorter hospital stay, faster recovery, and earlier return to regular activities. Those are general advantages,” Cookson says. “Specific advantages to individual procedures may also be of benefit to the patient and the health care system. For example, compared to open prostate surgery, robotic surgery allows for less blood loss and reduced internal scarring at the ‘hook up’ or anastomosis.”
Cookson explains that robotic prostatectomy is, by definition, laparoscopic but includes the robotic arms and equipment to allow for enhanced surgical movement with actions that mimic those achievable with your own wrist.
“In simple terms, laparoscopy is ‘straight sticks’ and can be quite useful for removal of small organs, like the gallbladder, or hernia repairs,” he says. “However, in more complex situations, the robotic technology allows the surgeon to offer many of the same operations that were previously performed open with the minimally invasive approach – procedures that require not only removal of an organ but also reconstruction. The latter is the part where robotics really allows the surgeon the ability to ‘put things back together.’
“For example, when you remove a cancerous prostate there is a reconstruction required to put the urethra back to the bladder neck. The prostate previously bridged that space, and once removed the two areas must be reattached to allow for proper healing. With the robotic technology, this is usually easily accomplished with 10 [times] power magnification and a watertight closure.”
Cookson says to accomplish this, the abdomen is inflated with carbon dioxide, then laparoscopic ports are placed in the abdomen under direct vision.
“In addition to a camera, three to five additional access ports, or trochars, are placed,” he says. “Through these trochars, the robotic arms and instruments are loaded by the bedside assistant. The surgeon, sitting … beside the patient, can then control the movements of these arms and instruments with precision under clear vision that magnifies10X over regular vision. Once the surgery has been completed, the prostate is removed in a small bag through the camera port. The small incisions are then closed.”
According to Cookson, robotic surgery has been particularly beneficial for urologic cancer surgery.
“For prostate cancer, about 85 percent of all surgeries (radical prostatectomies) in the United States this year will be performed robotically,” he says. “The reasons include the decreased blood loss, reduced pain, shorter hospital stay and more rapid convalescence. In addition, removals of small renal masses (partial nephrectomies) are being performed increasingly via a minimally invasive and robotic approach. The robotic technology allows for the complex reconstruction of the kidney after the cancerous mass has been excised.”
He adds that radical cystectomy, the removal of the bladder, and urinary reconstruction are also being performed with robotic use.
Another medical field benefiting from robotic technology is thoracic surgery. Dr. Subrato J. Deb, director of thoracic surgical oncology at the Stephenson Cancer Center, is an associate professor of cardiothoracic surgery at the OU College of Medicine.
“Robotic technology is one approach to minimally invasive surgery,” Deb says. “The benefits are in places where a small space requires dissection and where robotic technology offers advantages [when] other minimally invasive approaches are limited. One place is the mediastinum. Another is the superior sulcus, where neurogenic tumors often arise.”
Deb says robotic surgery offers advantages in a few specific areas where current thorascopic approaches are limited. He also notes that robotic technology continues to evolve and its applications may broaden in the future.
Dr. Peter Baik, a thoracic surgeon with Cancer Treatment Centers of America in Tulsa, says video-assisted thoracic surgery (or VATS) has influenced how physicians approach a patient’s treatment plan.
“Prior to … VATS, many referring physicians may not have considered surgery as an option due to the morbidities associated with thoracotomies,” Baik says. “[F]or example, any small suspicious enlarging nodules that could not be needle biopsied were just followed with repeat imaging (CT scan, chest X-ray, etc.) until the nodules became larger. If the suspected nodule is found to be cancer, it had time to spread to other areas. Now, a patient can get a resection of the nodule robotically, then be discharged … the next day. This allows even greater ability to diagnose, stage and treat patients earlier in their disease.”
He says robotic surgery has been especially useful in the resection of tumors, such as thymomas, in the cavity that separates the lungs from the rest of the chest.
“Thymomas were traditionally resected through median sternotomy, the same incision used during open-heart surgeries,” Baik says. “In addition to possible wound complications, the recovery is prolonged after sternotomy due to significant pain. The usual hospital stay after a median sternotomy is about five days. However, with robotic approach, several small incisions are made, along with a slightly larger incision, to remove the specimen. And the usual hospital stay after robotic resection of thymoma is around one to three days.”
However, Baik emphasizes that technological advancements are only useful when a patient is correctly diagnosed and given an accurate stage of a cancer’s progress, and alternatives are explored.
“For example, if a lung cancer patient is not correctly staged, the approach used for the surgery is less valuable,” Baik says. “[A]lthough the surgeries being performed are minimally invasive, the major portion of the procedure (i.e. removal of lung and lymph nodes) is the same as thoracotomy. Therefore, minimally invasive does not mean less risky surgery.
While robotics is transforming health care, it’s also shaping medical training. The Oklahoma State University Center for Health Sciences in Tulsa recently began construction on a state-of-the-art training facility that will utilize the latest innovations in robotic training technology.
The A.R. and Marylouise Tandy Medical Academic Building will feature a four-unit hospital simulation center with an emergency room, operating room, intensive-care unit, birthing suite and ambulance bay. Completion is expected in 2017.
“The medical simulation exercises that will take place in the Tandy Medical Academic Building are ultimately about providing better care for patients and their families,” says Dr. Kayse Shrum, president of the OSU Center for Health Sciences and dean of the College of Osteopathic Medicine. “Students will have a safe environment to apply what they have learned in the classroom into clinical practice. By working with human-like, state-of-the-art mannequins, our students will be able to acquire valuable clinical skills and become better physicians without having to put human patients at risk.”
David Knight, a simulation specialist for the OSU Center for Health Sciences, says the programmable mannequins can simulate any scenario, from a premature baby to an ill or injured adult.
“These ‘patients’ will be cared for in a two-bed emergency room, intensive-care unit, labor and delivery, and surgery simulation suites,” Knight says. “The most life-like simulation may be the human wearable surgery suit, where a person can strap on a torso that can be operated on.”
The 84,000-square-foot facility will include an expanded clinical skills lab, an osteopathic manipulative medicine lab, classrooms, two lecture halls and conference facilities. To accommodate a growing student population, the building will include more than 20 breakout rooms, 55 study carrels, a student kitchen and additional faculty and staff office space.