Urology: the Robotic cancer web site

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."

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What is Robotic Surgery?
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"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."

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