Anesthesia for Robotic Surgery

What Is a Robot?

According to Merriam-Webster, a robot is “a machine that resembles a living creature in being capable of moving independently (as by walking or rolling on wheels) and performing complex actions (such as grasping and moving objects).” Developed in the 1980s by the National Aeronautics and Space Administration (NASA), a robot is a remotely controlled device that allows tasks to be performed in spaces removed from human presence. Eventually, robots began to perform tasks aboard NASA spaceships. While the initial concept of robotic science was useful in space exploration, the U.S. government began looking for other applications of the technology.

The US Department of Defense (DOD) began working to apply the robots that were useful in space to the battlefield. Recognizing that an inordinate number of American soldiers died on the battlefield from hemorrhage or untreated surgical wounds, the DOD looked to use these technologies in surgical theaters. With the goal of having a surgeon remotely operate on patients in difficult-to-reach locations, the military invested in developing remotely controlled articulating arms that could perform surgical procedures.

At the same time, the world’s first laparoscopic cholecystectomy was performed in France. This procedure forever altered the course of traditional surgery, and the minimally invasive era of surgical procedures began.

Over the next decade, several companies developed a variety of medical robots and rapidly advanced the science. The first such device appeared in the early 1990s, when an instrument was created to pulverize bone and create space for hip prosthesis during orthopedic surgery.

As work progressed on creating devices to perform procedures, work also continued on allowing remote control of devices. In the mid-1990s, voice recognition software was used to control a laparoscope’s position and to aid in organ retraction during traditional laparoscopic surgery. This device, called Automated Endoscopic System for Optimal Positioning (AESOP), is still available today ( Fig. 71.1 ). In many ways, this device was the precursor to the smart devices in our homes and on our persons.

Arguably the greatest advancement in robotic surgery occurred in 1991 when a master-slave version of a robot was developed. This device allowed a surgeon to sit apart from his/her patient and remotely control articulating arms. Two similar devices, the da Vinci Robotic Surgical System, and the ZEUS Surgical System, appeared on the market at similar times. The parent company of da Vinci, Intuitive Surgical, acquired the intellectual property rights to the ZEUS system and discontinued the product. As a result, only the da Vinci Robotic Surgical System is available for use today ( Fig. 71.2 ).

Eventually, high-definition, three-dimensional cameras were added to robots, allowing surgeons to explore a patient’s anatomy and access traditionally difficult-to-reach surgical sites from a console located next to the operating table. While several robotic companies have developed products, at the moment, only two remain: AESOP and da Vinci.

The da Vinci robot has four components ( Figs. 71.2 and 71.3 ):

• 1.

  Surgeon console ( Figs. 71.4 to 71.6 )

  
  
  

• 2.

  EndoWrist instruments ( Figs. 71.7 and 71.8 )

  
  

• 3.

  Optical vision cart

• 4.

  Patient cart with four movable arms ( Fig. 71.9 )

  

The surgeon sits at the surgeon console (see Figs. 71.4 and 71.5 ) and remotely controls the EndoWrist instruments that are attached to the patient cart. Anesthesia personnel, surgical assistants, and circulating nursing staff may see the procedure in real time via the screen on the optical vision cart (see Fig. 71.2 ).

During an operation, the surgeon views two high-definition monitors that mimic a binocular or microscope. This two-monitor view creates three-dimensional images. The surgeon’s arms rest on the master controls, and his/her fingers manipulate the levers that control EndoWrist articulation. Foot pedals control electrocautery, movement of the robotic camera, and disengagement of robotic instruments. To facilitate collaboration and training, the da Vinci machine will often have two consoles allowing two surgeons to participate in the patient’s care.

Why Is the Robot Preferred?

The robot is preferred to open procedures because it allows a minimally invasive approach to surgical pathologies. Less tissue manipulation leads to fewer adhesions and potentially faster recovery from surgery. Fewer wound complications, including infections and incisional hernias, and shorter hospitalizations make robotic surgery attractive when compared to other minimally invasive or open techniques. Further, the robotic approach to surgical procedures allows discrete movements that are helpful in microsurgical dissection and re-attachment of tissues. In comparison with human arms, robotic arms permit seven degrees of free movement. These movements can be categorized into: gross arm movement by the da Vinci robot, fine movements by the articulating arms, and surgical actions performed by the articulating arms ( Table 71.1 , Figs. 71.7 and 71.8 ).

These articulating arms are not limited by constraints associated with human wrist joints. Additionally, the robot allows for larger, more coarse movements to be miniaturized in the operating field. For example, moving the controls by 5 mm may move the articulating arms by only 1 mm. This miniaturization permits more fine control. Furthermore, robotic software can reduce or eliminate hand tremors, thereby improving the safety and precision of surgery.

When Is the Robot Used?

The robot is used in hysterectomy, prostatectomy, nephrectomy, cardiac surgery, colectomy, general laparoscopic, thoracoscopic, and transoral otolaryngologic procedures. Although most procedures performed using the da Vinci robot are urologic (prostatectomy) and gynecologic (hysterectomy), a wide range of new applications are being discovered.

Essentially, robotic surgery is helpful whenever microsurgery is necessary and the target organ is difficult to reach. It is especially valuable if its usage converts what is traditionally an open procedure to a minimally invasive procedure.

Future Applications of Robotic Surgery

As imaging modalities and artificial intelligence are applied to robotic surgery, the field will evolve. It is probable that nonrigid, flexible articulating arms of progressively smaller size will ultimately replace the current, rigid articulating arms. “Snake-like” articulating arms will facilitate fewer and smaller incisions to be made in a patient and allow less invasive, perhaps even scar-free, surgery to be performed. Finally, as artificial intelligence evolves, it is possible that semi-autonomous robotic surgery will develop with computer algorithms guiding surgical instruments.