Robots et chirurgie : la télé chirurgie ou chirurgie mini invasive: novembre 2005

Bloodless Prostate Cancer Surgery

"The last few years have been witness to significant advances in our ability to treat prostate cancer. Surgery has been the gold standard of treatment for cancer cure, but complications of impotence and incontinence, prolonged hospital stays and risks of blood loss have been cited as incentives for patients to seek out less invasive approaches, even if success rates were not quite as high. ROBOTIC PROSTATECTOMY represents a quantum leap forward in our ability to effectively treat prostate cancer, reduce hospital stays, and minimize the risk of complications. In addition, in my opinion, the long term sexual and urinary bother symptoms will be less than for current surgical techniques or any form of radiation therapy as well."

==> View Robotic Surgery Urology Procedures: click here.

What is Robotic Surgery?
Read more: click here.

"Robotic surgery is an extension of laparoscopic surgery. Most people are familiar with laparoscopy. Surgery is performed by manipulating straight instruments while viewing the instruments on a monitor. Robotic surgery is the evolution of laparoscopy that addresses the drawbacks of laparoscopy.

One obstacle of laparoscopy is the loss of 3-D spatial relationships since the 2-D monitor is used to operate. The da Vinci Surgical System® uses a laparoscope that is comprised of 2 cameras and lenses to provide the surgeon with a true minimally invasive 3-D view of the surgical field including depth of field, magnification and high resolution.

Laparoscopic instruments have the feel of "chop sticks". The da Vinci Surgical Cart® includes the EndoWrist ® Instruments. The EndoWrist® Instruments are designed to mimic the movement of the human hands, wrists and fingers. The extensive range of motion allows precision that is not available in standard minimally invasive procedures.

Laparoscopic surgery places the surgeon in an uncomfortable position that can lead to a higher rate of surgical errors. The Da Vinci Surgeon Console® contains the master controls that the surgeon uses to manipulate the EndoWrist® instruments. The handles or 'Masters' translate the surgeon's natural hand and wrist movements into corresponding, precise and scaled movements. The EndoWrist Instruments® are only able to move when commanded by the surgeon. There is a clutch that deactivates the instruments and allows the surgeon to maintain a comfortable position at all times."

How does the robot work?

"The da Vinci® Surgical System combines proprietary software and electronics that create surgical immersion. The Surgeon's Console gives doctors the control and ability to navigate inside the patient. The InSite® Vision System immerses surgeons in a true-to-life 3-D image. The Navigator™ Camera Control allows the surgeon to easily change, move, zoom and rotate his or her field of vision. The camera can be repositioned quickly and smoothly within the surgical opening without disrupting the procedure.

The EndoWrist®Instruments transform movement of the doctor's wrists, hands and fingers into movement of the tiny instruments.

The da Vinci® Surgical System is the only commercially available technology that can provide the surgeon with the intuitive control, range of motion, fine tissue manipulation capability and 3-D visualization characteristic of open surgery, while simultaneously allowing the surgeon to work through small ports of minimally invasive surgery.

Using the da Vinci® System, surgeons can operate with the look and feel of open surgery, performing complex surgical maneuvers through 1-cm ports."

What makes robotic surgery better?

"With its 3-D view, the da Vinci Surgical System aids the surgeon to more easily identify vital anatomy such as the delicate nerves and blood vessels surrounding specific anatomy. The EndoWrist® Instruments provide the surgeon with the dexterity not available using conventional laparoscopic instruments to perform a delicate and precise surgical dissection , reconstruction or removal of specific tissue. The da Vinci® Surgical System is groundbreaking technology that extends the surgeon's capabilities in the following ways:

=> Enhanced 3-D Visualization: Provides the surgeon with a true 3-dimensional view of the operating field. This direct and natural hand-eye instrument alignment is similar to open surgery with 'all-around' vision and the ability to zoom-in and zoom-out.

=> Improved Dexterity: Provides the surgeon with instinctive operative controls that make complex MIS (Minimally Invasive Surgery) procedures feel more like open surgery than laparoscopic surgery.

=> Greater Surgical Precision: Permits the surgeon to move instruments with such accuracy that the current definition of surgical precision is exceeded.

=> Improved Access: Surgeons perform complex surgical maneuvers through 1-cm ports, eliminating the need for large traumatic incisions.

=> Increased Range of Motion: EndoWrist® Instruments restore full range of motion and ability to rotate instruments more than 360 degrees through tiny incisions.

=> Reproducibility: Enhances the surgeon's ability to repetitively perform technically precise maneuvers such as endoscopic suturing and dissection."

=> The Robotic Operating Room:

1. What does an operating room need to house a da Vinci robot?
2. What staff are required?

"The only requirement for the operating room is the operating room size. The unit consists of a console that the surgeon sits at and the robot that needs to be wheeled in towards the patient. These pieces cant be too close while the patient is entering the OR suite as you need to have freedom for people to walk around.

The other components for the operation are components you would need for all surgery or laparoscopic surgery.

Laparoscopic equipment: TV monitors for the assistant and nurses, air insufflator, light source.

Standard equipment: cautery generators, suction canisters, anesthesia setup.

In our hospital there is only 1 room that is large enough for the robot to work in. The robot, although weighing in excess of 1000 pounds (I think) is relatively easy to move around. We move it to other parts of the operating room to practice with it and easily move it around the room between cases if we are doing 2 different operations that day.

Our hospital is building 3 state of the art laparoscopic suites which should have all the screens and lap equipment hanging from the ceiling. I am told there will be a 42 inch plasma on the wall for everyone in the OR to see. Teleconferencing will also be available and my expectation is to have surgeons from all over the country and world come learn how to do some of the advanced robotic procedures we are doing at NBI currently.

I am hoping that the next generation of robots will be integrated into the operating theaters and will need less space.

What staff are required?
The main difference between this surgery and previous surgeries is that the surgeon is not at the field. I am currently performing surgeries with another urologist, but plan on hiring and training a physician assistant or nurse first assist to help. 90% of the operations can be just as safely, quickly, and precisely performed with a qualified non-physician assisting after the learning curve has been passed.

The anesthesia requirements are the same as any surgery except a full general anesthetic is needed (not a spinal). The blood loss is much less, as are the fluid shifts as compared to open surgery, so I would consider most cases low stress for the anesthesiologist.

The scrub nurse is the same as any operation. She does much less work than open once there is an experienced robotic team since the amount of instrument changes, sutures, etc. is less as compared to open surgery.

The circulating nurse is also necessary, as we sometimes use different devices from special clips or staples depening on the anatomy.

The only time that additional people are nice to have in the room is the setup and docking of the robot and the removal of the robot. We have developed several ways to remove steps to make this process as streamlined as possible.

Compared to open or lap surgery, the staff requirements are similar. The room size is the only difference with a large room needed for robotics."

Sources:
1.- Associates in Urology: da Vinci® Prostatectomy Robotic Surgery
==> Link to the web site: click here.

2.- Blog:
==> ROBOTIC SURGERY BLOG: click here.

"Haptics - A robotic limitation:"

"The most cited drawback of robotic surgery is the loss of fine feeling of the instruments on tissue.

The other drawbacks are the expense of the surgical system and the need for precise positioning of the robotic arms to provide for a full range of motion without repositioning the arms.

Haptics refers to the feedback of moving the robotic controls on the surgeon.

The current version of the da Vinci robotic surgical system does not have haptics Incorporated into the system. I admit it would be nice for the next version of the system to have haptics and enable the surgeon to feel the tension on sutures, as well as the tension of instruments on tissue.

The robotic radical prostatectomy procedure is a delicate urologic procedures that is a good one to use in discussing haptics.

In my opinion, the loss of feedback is not a major or significant drawback. Although I think it will make the robot easier to use and possibly a little safer, the 10 times magnification more than makes up for this shortfall. We have different senses that are used to some extent in surgery. The sense of sight allows us to see tension in tissue and sutures. As long as the instruments are kept in the field of view, the loss of fine sense of feel is not a problem for me.

There is a limited sense of feel with the da Vinci. When instruments have tension, eventually it will be felt in the instruments. When I am retracting the prostate with my left hand, I feel the tension when it gets to a certain level, granted not as soon as I would with me hands. When I lift on the vas and seminal vesicles with my 4th arm, I can feel the tension in the instrument. If my instruments are colliding with each other, or with the bony side wall, or with a laparoscopic instrument the instruments don't move as smooth as usual.
To date I have performed 65 robotic operations and 49 prostate operations and have not had any complications related to lack of haptics. I haven't had any vessel or bowel injuries."

Continue reading: "Haptics - A robotic limitation":
==> click here.

Je me suis décidée à écrire sur ce sujet aux frontières entre la vie et la mort, la mort et la vie, un no man’s land où nous, chirurgiens et chirurgiennes, procédons en passeurs anonymes à des échanges clandestins. Nous passons ces frontières en clandestins : «Non, je n’ai rien à déclarer» (ce territoire ne fait pas encore partie de l’espace Schengen). «Valise diplomatique !». Je brandis mon I.D. justifiant mon Immunité Diplomatique, et je franchis sans histoire les frontières successives, avec ma précieuse valise, que personne ne m’a demandé d’ouvrir. En général, à ce moment là, des images m’accompagnent : un ange aux ailes de sang. Pourquoi du sang ? J’ai dû essayer de faire rentrer mes ailes dans les gants chirurgicaux. Pas précisément adaptés. Je saigne, je sais, ça fait partie du métier. «Le sang coule, c’est le métier qui rentre». «Ce qui ne détruit pas rend plus fort». Ces phrases reviennent souvent dans la bouche de mes collègues. Des phrases pour cimenter les briques des épreuves.

Quand j’étais étudiante en première année de médecine, l’année du redoutable concours, l’amphi était bondé en début d’année. Un de nos profs procéda à un écrémage selon une recette maison, sans attendre le concours : «En faisant médecine, vous vous préparez à passer votre vie dans le sang, l’urine, la merde et le vomi. Ceux que ça gêne, il faut qu’ils partent à côté : ils apprendront à vendre des savonnettes». Trois cours plus tard, un bon quart des étudiants avait déserté l’amphi pour de bon. A la grande satisfaction du prof. En même temps que le sang et compagnie, il aurait dû mentionner le manque de sommeil. Parler du sommeil à un «chir.» (c’est comme ça qu’on nous appelle dans le métier) équivaut à parler du sucre à un diabétique. Orgie de douceur vengeresse qui me traverse, dans le sillage de l’ange aux ailes de sang.

Depuis 5 ans, je supervise les internes dans le service de chirurgie pédiatrique d’un grand hôpital parisien. Les usagers de la santé nous tiennent pour des scientifiques, des grands prêtres de la Science Exacte : chirurgie assistée par ordinateur pour opérer les organes mous en endoscopie, chirurgie au laser, robot pour opérer la cataracte, système high-tech de chirurgie assistée par ordinateur pour la pose de prothèses de genoux : la précision chirurgicale est devenue numérique. La chirurgie, c’est Matrix ; le chirurgien, c’est James Bond. Comme l’espion britannique de Sa Majesté, j’utilise la technologie de pointe en m’efforçant de ne pas faire de vagues. «Painless civilization». C’est le package que l’hôpital vend à l’usager de la santé. Un ami qui est comptable dans une clinique privée m'a repris l’autre jour : «Tu ne dois plus parler de malade ou de patient. Il faut parler de client». Je lui ai répondu : «Pour une fois que la compta et le marketing s’entendent !... D’habitude, le marketing dépense des sous et la compta râle».

«On va opérer votre petite Mélanie en chirurgie mini invasive, à cœur battant. Pas besoin de lui ouvrir la cage thoracique, il suffira de pratiquer quelques incisions minimes. Pas besoin de lui casser les côtes, pas besoin non plus d’utiliser le CEC (Système de Circulation Extracorporelle) qui gère l’arrêt temporaire du cœur et des poumons, la circulation du sang s’effectuant en 'itinéraire bis' pendant ce temps, grâce à une machine qui relaye les fonctions cardio-pulmonaires, tout ceci après ouverture de la cage thoracique et écartement des côtes. Lorsqu’on utilise cette méthode de chirurgie traditionnelle invasive, on opère ‘à ciel ouvert’, comme disent les chirurgiens. Pour Mélanie, plus besoin de tout ça. Par les toutes petites incisions qu’on pratiquera sur son thorax, on entrera les instruments destinés à opérer. Un chirurgien assis à une console équipée d’une image en 3D et d’un système infrarouge commandera, ou téléguidera, si vous voulez, les mouvements des instruments opérant à cœur battant. Vous voyez, ce n’est pas le robot qui opère, c’est le chirurgien, pour autant plus besoin d’ouvrir le thorax et d’utiliser la CEC. Rassurez-vous, c’est une opération pratiquée couramment aujourd’hui, votre petite fille sera sortie de l’hôpital et totalement rétablie en 3 jours». Tandis que je parle ainsi à la mère de ma petite patiente de 6 ans, l’ange aux ailes de sang me traverse à nouveau, cette fois-ci, il opère à ciel ouvert. Le fruit de vos entrailles est béni !

Chirurgie mini invasive, coelioscopie, etc. : je suis une chirurgienne informatisée, et je veille à avoir les derniers logiciels. Ils viennent de Californie. Silicon Valley, l’université de Stanford, l’UCLA (University of California, Los Angeles), etc. Le progrès est relégué au grenier. Nous sommes à l’ère des technologies, biotechnologies, bioéthique, éthique médicale. L’autre jour j’ai lu un article dans le NEJM, le très sérieux «New England Journal of Medicine», écrit par un «Medical Bioethicist PHD». J’ai mis un moment avant de déchiffrer ce que recouvrait exactement ce terme barbare. C’est dans la langue de Shakespeare, mais ce n’est pas du Shakespeare ! En salle de garde, un interne résume la situation : «La biotechnologie, c’est de la technologie bio. Et la bioéthique, c’est pour réfléchir là-dessus. Internet ; l’intranet et l’extranet, tout ça c’est bio, comme 'la Vie Claire'. Puisqu’on nous promet des écrans organiques pour nos ordinateurs de demain… Jamais entendu parler des écrans OLED ?»

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