06 Oct 2011
By: NG WAN CHING
A surgeon now does more than cut and sew. Increasingly, he is a pilot and navigator as well, with the rise of robotic surgical systems.
More and more, a surgeon is apt to sit at a console and control the movements of miniature instruments attached to robotic arms.
The surgeon sees through a tiny but powerful camera on the end of a robotic arm. These arms are inserted into the body through several small incisions.
These robotic surgical systems offer three-dimensional (3-D) vision and their robotic hands can reach deep into a patient’s body, for example, the pelvis. These hands are able to mimic the human wrist, so they are able to do very neat and precise stitching.
The surgeon thus has more range of motion, better visibility and more precision.
The aim: to perform surgery in hard-to-get-to places or to leave as little damage as possible to the surrounding tissue.
This is the future of surgery and at least five hospitals here now use robotics.
The latest to do so were KK Women’s and Children’s Hospital (KKH), which bought its robot last month; and Tan Tock Seng Hospital (TTSH), which bought its robot in May last year and now uses it for nine in 10 prostate operations.
The first robotic-assisted surgery performed in 1995 in the United States utilised a robotic platform to eliminate the need for an assistant to hold the camera during laparoscopic procedures. These procedures are done by inserting instruments through a few small incisions in the body.
The more contemporary da Vinci system represents the next evolutionary step.
Its four arms allow control of surgical optics and simultaneous manipulation of tiny surgical tools.
With a human surgeon at the controls, it filters out tremors, enhances precision, offers 3-D imaging and may eliminate some of the fatigue associated with conventional laparoscopic surgery.
In the more than 10 years since the United States Food and Drug Administration (FDA) approved the first robotic surgical system for conducting abdominal and pelvic operations, its use has skyrocketed.
The da Vinci surgical system, which costs about $3 million, is now used for more than 80per cent of prostate cancer surgery performed annually in the US.
Dr Chong Yew Lam, head and consultant urologist at TTSH, noted that this year marks the 10th anniversary of robotic prostate cancer surgery. It was first done by Dr Mani Menon at the Henry Ford Hospital in Detroit, US.
In Singapore, Singapore General Hospital (SGH) was the first to buy a da Vinci robot in 2003, mainly for prostate cancer surgery.
Mount Elizabeth Hospital bought the robotic surgical system in 2004 and the National University Hospital (NUH) did so in 2008.
At SGH, the benefits were obvious from the start with patients recovering faster and losing less blood.
As time went by, the hospital added bladder cancer surgery and kidney cancer surgery to the uses for the da Vinci system.
The hospital now does 110 robotic operations of various kinds a year, including those for colorectal cancers and thyroid and gynaecologic surgery.
But the majority is still for prostate cancer surgery, said Professor Christopher Cheng, senior consultant at the department of urology at SGH.
As robotic technology extends the reach of minimally invasive surgery to places like the deep pelvis, it will be widely used in the future, said Professor London Lucien Ooi, chairman of the division of surgery at SGH.
“Often, conventional open instruments and the surgeon’s hands are not able to reach deep in the pelvis. With the robot, the vital pelvic structures are magnified and the robotic arms are able to reach areas conventional open surgery is not able to,” he said.
Tissues are magnified several-fold and in high definition, so seeing what they are doing has never been easier for surgeons.
One day, the robot, adapted to all kinds of uses, could be a mainstay in the operating theatre.
Prof Ooi said: “The future of surgery could see multiple robots in every hospital. That might be possible if their use becomes more commonplace.”
Right now, not every kind of procedure lends itself to robotic technology. For example, knee and hip replacements and transplant surgery still require open surgery.
But more types of surgery are being added to the list all the time, including colon and rectum resections, cardio-thoracic procedures, thyroid surgery and the removal of fibroids and the womb.
At NUH, surgeons are taking robotic surgery further, using it to accomplish more than one kind of procedure at the same time.
Recently, gynaecological and colorectal surgeons at NUH used a robotic system to remove part of a uterus in a patient with uterine cancer, and then a tumour in the small bowel that was unrelated to the uterine cancer, said Dr Dean Koh, senior consultant at the division of colorectal surgery at NUH.
It saved the patient from having to undergo two separate operations to remove her tumours.
Dr Koh, who is also the vice-chairman for the Robotic Accreditation, Procedural Implementation and Development (Rapid) committee at NUH, said: “I believe that moving forward, this type of combined operations can and will be performed with the robotic system if the expertise is available.”
In 2008, NUH set up a unit,
Graces@NUH, which stands for Gynaecologic Robot Assisted Cancer & Endoscopic Surgery, to explore the use of robots in gynaecological surgery.
Dr Joseph Ng, chairman of the unit, said: “Robotic surgery combines the advantages of traditional open surgery and keyhole surgery. It also allows the surgeon to see in three-dimensions.”
Many studies have established that robotic gynaecological surgery beats conventional open surgery on many counts: shorter hospital stay, reduced blood loss and reduced risk of complications such as fever and acute renal failure.
But there is a steep learning curve for surgeons, said Prof Ooi.
SGH has invested in a dual console robotic system, which not only allows two different procedures to be done at the same time, but also surgeons and trainees to teach and learn on the same platform.
Prof Ooi said: “It allows the surgeon and trainee to be a pilot and co-pilot, where they can have immediate handover of the surgery from one to another.”
Currently, there is only one robot – the da Vinci – and it is bulky and heavy.
But it will not be long before a surgeon can board a plane carrying a robot and use it to operate at his destination, said Adjunct Professor Eu Kong Weng, senior consultant surgeon and chief of Pacific Surgical and Colorectal Centre.
At KKH, which does two or three robot-assisted operations a week now, Associate Professor Bernard Chern said it is just a matter of time before robots get smaller and less unwieldy, and the scope of their use broadens.
By that time, costs will also come down with greater use, he said.
“This technology will be increasingly more widespread and available to more patients,” said the deputy chairman at the division of obstetrics and gynaecology, and senior consultant and head of the minimally invasive surgery unit at KKH.
Dr Tay Hin Ngan, consultant at the department of otolaryngology at SGH, said: “Laparoscopic or endoscopic surgery has probably reached its limits. With robotic technology evolving relentlessly and instruments becoming more site- or surgery-specific, the future lies with the robot.”
Pros and cons of using a mechanical surgeon
ADVANTAGES
Patients experience:
1 Faster recovery
2 Less pain
3 Less bleeding
4 Greater preservation of vital structures, such as the pelvic nerves, which are important for sexual, urinary and bowel functions; and the anal sphincter muscles, which are needed for bowel movements.
5 Less chance of needing a permanent stoma, an opening in the abdomen from which waste empties into an attached bag, when doing difficult operations to remove certain types of rectal cancer.
6 Less post-operative ileus (bowel dysfunction)
7 Better aesthetic results
Surgeons experience:
1 Immensely improved depth perception. The stereoscopic, three-dimensional optical image is magnified and in high definition.
2 Stable camera platform and instruments. The surgeon, rather than an assistant, controls the camera. Motion-scaling and tremor-eradication technology removes the natural tremors of the surgeon’s hand, so the camera and instruments do not shake, making the operation more precise.
3 Three operating arms that the surgeon can toggle between, instead of just two with laparoscopic surgery.
4 Wide range of motion for the instruments, as opposed to limited motion in laparoscopy. This gives better dexterity, precision and accessibility especially in tight spaces.
5 Fewer issues with fatigue. The surgeon can use the robotic arms for cutting and providing better tissue exposure during surgery. Tissue exposure helps the surgeon see what he is operating on better and leads to more precision.
LIMITATIONS
1 One area where conventional open surgery may be better than robotic surgery is when one has previously undergone multiple abdominal surgery, whereby there may be internal scarring, or what is known as adhesions.
2 High cost of robotic-assisted surgery
3 Steep learning curve for surgeons
Email: wanching@sph.com.sg
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