9.robotics in surgery powerpoint presentation.ppt
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robotics in surgeryTRANSCRIPT
Robotics in SurgeryRobotics in Surgery
Marc S. Milsten, M.D., F.A.C.S.Marc S. Milsten, M.D., F.A.C.S.Urologic Specialists of Urologic Specialists of
OklahomaOklahomaNovember 17, 2007November 17, 2007
Definition of a RobotDefinition of a Robot
Machine that resembles a human Machine that resembles a human and does mechanical, routine tasks and does mechanical, routine tasks on commandon command
Any mechanical device that operates Any mechanical device that operates automatically with human-like skillautomatically with human-like skill
““A robot is not a machine….it is an A robot is not a machine….it is an information system with arms”information system with arms”
Robots: Better Than Robots: Better Than Humans?Humans?
Robots: Better Than Robots: Better Than Humans?Humans?
Types of RobotsTypes of Robots
Passive Passive Retractor systemRetractor systemPosition the tool and then hold Position the tool and then hold
ActiveActiveRobot would actively move the tool Robot would actively move the tool
upon the surgeons commandupon the surgeons command
Surgical Robots in 2007Surgical Robots in 2007
AESOP (Automated Endoscopic AESOP (Automated Endoscopic System for Optimal Positioning)System for Optimal Positioning)- Voice activated mechanical arm- Voice activated mechanical arm- Steadier than human, never tires- Steadier than human, never tires
daVincidaVinci- FDA approval in 2002- FDA approval in 2002- Laparoscopic instrumentation - Laparoscopic instrumentation controlled by the surgeon positioned controlled by the surgeon positioned remotely at a consoleremotely at a console
Development of daVinciDevelopment of daVinci
Defense Advanced Research Projects Defense Advanced Research Projects Agency (DARPA) for military research Agency (DARPA) for military research of remote battlefield surgeryof remote battlefield surgery
Cholecystectomy performed remotely Cholecystectomy performed remotely via telesurgery from 300 miles awayvia telesurgery from 300 miles away
Intuitive Surgical created in 1999 after Intuitive Surgical created in 1999 after acquiring patent rights from militaryacquiring patent rights from military
First robotic prostatectomy performed First robotic prostatectomy performed in 2001in 2001
““Operation Lindberg”:Operation Lindberg”:Remote Transatlantic Remote Transatlantic
TelesurgeryTelesurgery
Remote Surgery
Advantages of Laparoscopic Advantages of Laparoscopic SurgerySurgery
Shorter hospital stayShorter hospital stayLess painLess painLess risk of infectionLess risk of infectionLess blood loss and transfusionsLess blood loss and transfusionsLess scarringLess scarringFaster recovery Faster recovery Quicker return to normal activities Quicker return to normal activities
Challenges of Laparoscopic Challenges of Laparoscopic ProstatectomyProstatectomy
Prostate located in fixed confines of Prostate located in fixed confines of pelvispelvis
Laparoscopic instruments limited in Laparoscopic instruments limited in articulated movementsarticulated movements
Approximation of bladder-urethral Approximation of bladder-urethral anastomosis difficult to sutureanastomosis difficult to suture
French experience: >300 cases French experience: >300 cases reported, learning curve >100reported, learning curve >100
Oklahoma experience: 1 case, 19 Oklahoma experience: 1 case, 19 hours, patient diedhours, patient died
Advantages of daVinci RobotAdvantages of daVinci Robot
Magnified (12x), stereoscopic 3-D Magnified (12x), stereoscopic 3-D visionvision
Robotic wrist with 6 degrees of Robotic wrist with 6 degrees of freedomfreedom
Movements are scaled, filtered, Movements are scaled, filtered, translatedtranslated
daVinci Robotic SystemdaVinci Robotic System
Disadvantages of daVinci Disadvantages of daVinci RobotRobot
ExpensiveExpensive- $1.4 million cost for machine- $1.4 million cost for machine- $120,000 annual maintenance - $120,000 annual maintenance contractcontract- Disposable instruments $2000/case- Disposable instruments $2000/case- Hospital reimbursement same DRG- Hospital reimbursement same DRG
Steep surgical learning curveSteep surgical learning curve Increased staff training/competanceIncreased staff training/competance Increased OR set-up/turnover timeIncreased OR set-up/turnover time
Robotic DisbelieversRobotic Disbelievers
““No long term data”No long term data”- Margin positive rates equivalent- Margin positive rates equivalent- No difference in risk for - No difference in risk for incontinence and incontinence and erectile erectile dysfunctiondysfunction
““Loss of tactile feedback”Loss of tactile feedback”- Improved vision- Improved vision- Haptic feedback: visual resistance- Haptic feedback: visual resistance
ENABLER: same operation, new toolENABLER: same operation, new tool
daVinci Robotic daVinci Robotic ProstatectomyProstatectomy
OpenOpen RoboticRobotic
OR timeOR time 3 hrs3 hrs 2-4 hrs2-4 hrs
Hospital stayHospital stay 3 days3 days 24 hrs24 hrs
Foley catheterFoley catheter 14 days14 days 7 days7 days
Blood lossBlood loss 600 ml600 ml <100ml<100ml
RecoveryRecovery 4-6 wks4-6 wks 2-3 wks2-3 wks
Margin PositivityMargin Positivity
SeriesSeries % Positive margins% Positive margins Soloway Soloway (Open)(Open) 28 %28 % LeporLepor (Open)(Open) 26 %26 % GuillonneauGuillonneau (Laparoscopic)(Laparoscopic) 13.7 %13.7 % AbbouAbbou (Laparoscopic)(Laparoscopic) 20%20% RassweilerRassweiler (Laparoscopic)(Laparoscopic) 24 %24 % TurkTurk (Laparoscopic)(Laparoscopic) 26 %26 % BollensBollens (Laparoscopic)(Laparoscopic) 22 %22 % SulserSulser (Laparoscopic)(Laparoscopic) 18%18% MenonMenon (Robotic)(Robotic) 26%, 17%, 6%26%, 17%, 6% AhleringAhlering (Robotic)(Robotic) 17%17% LeeLee (Robotic)(Robotic) 21%21%
Continence DataContinence Data
SurgeonSurgeon 3 mo 6 mo 3 mo 6 mo12 mo12 mo WalshWalsh (Open)(Open) 54 % 80% 93%54 % 80% 93%
AbbouAbbou (Laparoscopic) (Laparoscopic) 58%58% 69% 78%69% 78%
GuillonneauGuillonneau (Laparoscopic) (Laparoscopic) N/AN/A N/AN/A 85 % 85 %
RassweilerRassweiler (Laparoscopic) (Laparoscopic) 54%54% 74%74% 97% 97%
MenonMenon (Robotic)(Robotic) N/AN/A 96%96% N/A N/A
AhleringAhlering (Robotic)(Robotic) 76%76% 91%91% 94% 94%
LeeLee (Robotic)(Robotic) 60%60% 82%82% N/A N/A
Potency DataPotency Data
AuthorAuthor Capable of IntercourseCapable of Intercourse Walsh (age 60 to 67) (Open)Walsh (age 60 to 67) (Open) 75%75% Catalona (60’s/70’s) (Open)Catalona (60’s/70’s) (Open) 60% / 47%60% / 47% GuillonneauGuillonneau (Laparoscopic) (Laparoscopic) 66% overall66% overall AbbouAbbou (Laparoscopic) (Laparoscopic) 54%54% TurkTurk (Laparoscopic) (Laparoscopic) 59%59% MenonMenon (Robotic) (Robotic) 64%64% AhleringAhlering (Robotic) (Robotic) 65%65% Lee (Robotic)Lee (Robotic) Too Too
earlyearly
Tulsa daVinci ExperienceTulsa daVinci Experience
Machine located at St. JohnMachine located at St. John>130 prostatectomies performed to date>130 prostatectomies performed to dateAverage operative time 2-3 hoursAverage operative time 2-3 hours>95% patients discharged in <24 hours>95% patients discharged in <24 hoursNo conversions to open surgeryNo conversions to open surgeryComplications: 2 post-op bleed, 1 port Complications: 2 post-op bleed, 1 port
site hernia, 1 anastomotic stricturesite hernia, 1 anastomotic stricture
daVinci Clinical ApplicationsdaVinci Clinical Applications
Urology: radical prostatectomy, Urology: radical prostatectomy, dismembered pyeloplasty, radical dismembered pyeloplasty, radical cystectomy, cyst decorticationcystectomy, cyst decortication
Cardiac: mitral and aortic valve Cardiac: mitral and aortic valve replacement, aorto-iliac bypass, off-replacement, aorto-iliac bypass, off-pump synchronized bypasspump synchronized bypass
GYN: hysterectomy, prolapse repair, GYN: hysterectomy, prolapse repair, tubal reversals, fistula repair, tubal reversals, fistula repair, myomectomymyomectomy
General: gastric bypass, NissenGeneral: gastric bypass, Nissen
daVinci Clinical LimitationsdaVinci Clinical Limitations
No advantage over standard No advantage over standard laparscopic approach for laparscopic approach for cholecystectomy, spleenectomy, cholecystectomy, spleenectomy, colectomycolectomy
Increased operative time observedIncreased operative time observedPrecise dissection not necessaryPrecise dissection not necessaryOpen space: limitations with broad Open space: limitations with broad
sweeping motionssweeping motions
daVinci vs. LaparoscopydaVinci vs. Laparoscopy
Laparoscopic surgical fellow at StanfordLaparoscopic surgical fellow at StanfordFirst 50 Roux-en-Y procedures randomized First 50 Roux-en-Y procedures randomized
laparoscopic or robotic with DaVincilaparoscopic or robotic with DaVinciBoth surgery with hand-sewn anastomosisBoth surgery with hand-sewn anastomosisOR time: 149 min (lap) vs 131 min (robot)OR time: 149 min (lap) vs 131 min (robot)No difference for complications, LOS, EBLNo difference for complications, LOS, EBLConclusion: Robot is an ENABLERConclusion: Robot is an ENABLER
Off-pump CABGOff-pump CABG
30 patients, 2.6 grafts/patient30 patients, 2.6 grafts/patient Majority: IMA to LADMajority: IMA to LAD 15/30 discharged <24 hours15/30 discharged <24 hours Complications:Complications:
- 2 return to OR for bleeding- 2 return to OR for bleeding
- 1 converted to open- 1 converted to open
- 2 readmits: pleural effusion, wound - 2 readmits: pleural effusion, wound infectioninfection
No mortalityNo mortality
Advanced EndoscopyAdvanced Endoscopy
Natural Orifice Surgery
Courtesy of N Reddy, Hyperbad India 20005
Courtesy of N Reddy, Hyperbad India 20005
Peroral Transgastric Endoscopic SurgeryPeroral Transgastric Endoscopic SurgeryNatural Orifice Transluminal Endoscopic Surgery Natural Orifice Transluminal Endoscopic Surgery
(NOTES)(NOTES)
Trans-gastric AppendectomyTrans-gastric Appendectomy
Climbing the Learning CurveClimbing the Learning Curve
Standard surgery: “see one, do one, teach Standard surgery: “see one, do one, teach one”one”
Robotic surgery: “see one, do one, kill one”Robotic surgery: “see one, do one, kill one” Requires entirely new skill set beyond Requires entirely new skill set beyond
traditional surgical and laparoscopic trainingtraditional surgical and laparoscopic training Training opportunities limited Training opportunities limited Animal labs helpfulAnimal labs helpful Cases require outside proctor to determine Cases require outside proctor to determine
competencycompetency Credentialing challenges??Credentialing challenges??
Surgical SimulationSurgical Simulation
Surgical SimulationSurgical SimulationRed Dragon/Blue DragonRed Dragon/Blue Dragon
Hand Motion AssessmentHand Motion Assessment
Robotic RoundingRobotic Rounding
Robotic Scrub NurseRobotic Scrub Nurse“Penelope”“Penelope”
Robotic Scrub NurseRobotic Scrub Nurse
Operating Room of the FutureOperating Room of the Future
Moral DilemmaMoral Dilemma
Technology is neutral - it is neither good or evil
It is up to us to breathe the moral and ethical life into these technologies
And then apply them with empathy and compassion for each and every patient
ConclusionsConclusions
The rate of discovery of new technology The rate of discovery of new technology is outpacing the ability of business, is outpacing the ability of business, society, and healthcare to integrate and society, and healthcare to integrate and applyapply
Robotic surgery is but one example of Robotic surgery is but one example of such technology that MAY reduce such technology that MAY reduce operative morbidity, hospital stay, and operative morbidity, hospital stay, and recovery, while POTENTIALLY improving recovery, while POTENTIALLY improving clinical outcomes, but at what point do clinical outcomes, but at what point do the BENEFITS justify the increased the BENEFITS justify the increased EXPENSE?EXPENSE?