New frontiers in computer-assisted surgery

Robotic surgery is a type of surgery that is carried out via a sophisticated technology, involving the use of telemanipulators capable of reproducing, miniaturising the movements of th surgeon’s hands inside the body cavity or otherwise in the operating field. The word robot was first coined by Czech writer Karel Capek, to explain in the science- fiction novel “R.U.R.,-Rossum’s Universal Robots”, published in 1920, the androids that were designed to free mankind from the bondage of physical fatigue and which had a universal success.

The most common definition of robots is that which performs complex functions autonomously, providing an active interaction with its environment. The adjective, ‘robotic’ even though extremely widespread, is hence inappropriate in the case of surgery, misleading to understand that there is complete autonomy in all surgical operations and decision-making actions that, for the moment at least still do not exist. It is always the surgeon, even if through remote-control telemanipulator, who controls all the movements of the instruments performed during surgery. The necessity in using computers and miniature telemanipulators, arises from the need to perform more and more complex and sophisticated surgery, and due to the desire to reduce adverse effects in traumatic surgery. The growing awareness that many of the negative consequences in surgery are linked to global tissue trauma, and has led to the development of the concept of thoracoscopic and laparoscopic minimally-invasive surgery.

This was clinically developed starting from the 80’s, when the German gynecologist Kurt Semm performed the first laparoscopic appendectomy, which was so heavily disputed. Since then, the technique has been extended to many abdominal and thoracic surgeries. The method forsees the performance of surgery via a camera equipped with special instruments, which are then introduced into the body through tiny holes or notches. The positive aspects, some of which have already been proven and others still to be evaluated, are multiple. Reduced blood loss, reduced post-surgical pain, a hasty early recovery of normality in functions of the organs, a reduction in post-surgery infections, reducing hospitalization times and subsequent convalescence, premature work resumption, a decrease in post laparotomy syndrome adhesions, are but some of the most evident benefits.

Robotic-surgery, or computer-assisted telemanipulator, was born with the intention of solving the existing limitations in laparoscopic surgery. The interest in telesurgery (remote-surgery) started up in 1980 with studies on virtual realities at NASA (National Aeronautics and Space Administration). In the early 1990’s, NASA scientists in cooperation with researchers at the Stanford Research Institute (SRI), developed the dexterous telemanipulator. This work was then to be taken over by the army of the United States, with the intent of improving relief efforts in war-torn areas through the use of telepresence. Some of the professionals involved in these studies, subsequently gave rise to private companies, which used the principles of robotic surgery in civil circles. AESOP and ZEUS were the first examples of robotic surgical systems, manufactured by Computer Motion in Santa Barbara, California. In 1995, Intuitive Surgical was first established which patented SRI Green Telepresence Surgery System, later renamed da Vinci System, to be used for the first time in Europe in 1998 by Alain Carpentier in a cardiac operation. In 2000, the FDA (Food and Drug Administration) in the USA approved implementino the system in general and laparoscopic surgery. Over the years, the feasibility and safety in computer-assisted techniques have been demonstrated in multiple indications pertaining to urologic surgery, gynaecology, general thoracic and heart-surgery.

In September 2001, Jacques Marescaux dveloped for the first time cholecystectomy in transatlantic telesurgery, marking the beginning of a new era. This operation, called ‘Lindbergh’ in honour of the first pilot to cross the Atlantic, implemented the ZEUS system; the surgeon was in New York and the patient in Strasbourg. The Intuitive Surgical and Computer Motion merged in 2003 giving rise to a single company, Intuitive. The da Vinci system has undergone significant changes and improvements (fourth arm, high definition, dual console, new instruments). Systems currently active and registered throughout the world account for more than 1500. In Italy, 60 robots have been installed, and even though a few of them are full operating, up till now approximately 7000 operations have been carried out. Italy ranks third place in the world, preceded by the USA and France. As far as abdominal robotic surgery is concerned, its diffusion has been slower and more complex. And this for several reasons: there is often a need to work on more abdominal quadrants (abdomen cavities) simultaneously and there are difficulties in exposure of the surgical area, that can be improved changing positions of the operating table.

These factors have increased the complexity in regulating the system, in that, robotic surgery has its most compelling applications in certain fixed fields, restricted and deep. Moreover, in general surgery, some operations are easily and cost-wise accessible laparoscopy (e.g., cholecystectomy), while others are difficult to perform especially with minimally-invasive technique, is still a challenge (e.g., Hepatectomy and the pancreasectomy). Furthermore, the learning.curve, especially for an experienced surgeon in laparoscopy is shorter but as regards to more demanding operations, becomes an ordeal but should be ultimately pursued and extended to minimally-invasive surgey, where laparoscopy surgery has its limitations. Knowledge about both these techniques is a must in terms of cultural background of a surgeon living in the third millennium and the lack of tactile feedback, (e.g. how tight a surgical suture should be knotted), cannot and must not represent a limit offset by vision.

Indeed the presence of mirror neurons, which are activated both when performing a certain action or when we see an action performer by someone else, transmitting to our minds that the objects are connected directly to the movement. In other words, to our minds, the processes underlying the knowledge and perception of reality, which are based on how the characteristics of the objects themselves are perceived, experience in actions to be performed. All this, transferred to the implementation of robotic-surgery means, acquiring a good knowledge of traditional abdominal surgery and procedures involved, before adopting this new technique.

Recently, our clinic has embarked on this new methodology with enthusiasim and foresight. Currently, one/two robotic abdominal surgeries per week are being performed. The surgical fields where we apply the Da Vinci robotic system, which includes colic-resections, anterior resection of the rectum, abdominalperineal amputations-according to Miles, front Rettopessi robotics, surrenectomy and fundoplication sec. According to Nissen Robotic surgery is no longer solely a bet for the future, but a reality of the moment.

Mario Guerrieri
Surgical Clinic at ‘ Polytecnica University’ of Marche