No kingdom for a horse, but a lancet for a joystick in Robodoc's realm

Brussels 13 November 1999In the Saint Pierre Hospital in Brussels, the robot has chased the surgeon out of the operating theatre. Shortly, the same thing will happen in Utrecht where Intuitive Surgical's da Vinci telerobotic system will be used to perform bypass surgery on a patient's beating heart. Already, the surgeon of the future is practising on his PlayStation. Instead of manipulating a lancet, Cyberdoctor feels the touch of a joystick through his fingers, moving through an "empty space". Guided by sophisticated 3D computer images and changing camera positions, the surgeon has the impression of travelling within the patient's body. There is no haptic feedback, at least not yet, when cutting through bone or tightening the rope of a stitch. The appearance of Robodoc in the operation room definitely forces new skills upon the surgeon.


Professor Guy-Bernard Cadière seems to be lost in some game of mimic art, swinging his hands graciously through the air, during a complex gastro-intestinal operation. The surgeon is sitting at a control panel in the corner of the operation room, gazing in concentration at the monitor. With two joysticks, the physician makes little grasping movements to steer the instruments which are linked to the console. A web of cables connects the panel to the operating table, equipped with three robotic arms hanging above the patient's abdomen. Through small incisions, little stents pending from the mechanical arms, penetrate the body. Large screens are showing the surgical instruments inside the abdomen which are being controlled by the surgeon via the robotic arms.

The surgeon does not even need to be present in the operating theatre but is able to remotely perform the intervention from another location. The system allows to execute endoscopic and minimally invasive operations which were unthinkable in the past. Patients, submitted to endoscopy, suffer less pain and recover faster. Endoscopic techniques however require a tremendous skill from the surgeon, since he has a poor view of the operation field, lacks direct contact with the tissue and enjoys only limited freedom of movement. In addition, there is a change in left-right and up-down directions because the key-hole incision functions as a turning point for the surgical tools while any trembling of hands is reinforced at the end of the instrument. Therefore, the robot taking the place of the surgeon can mean a big step forward.

Last year, Intuitive Surgical and Computer Motion, two companies based in California, surprised the medical world with commercial surgical robots that depended on NASA-technology. In the meanwhile, both have sold each some fifteen pieces, mainly in Europe because legislation for medical experiments is more flexible here than in the United States. In fact, these systems are no real robots because they do not operate independently but should be viewed as an extension of the surgeon's hands, as Dr. Ivo Broeders at the University Medical Centre in Utrecht explains. Dr. Cadière from the Saint Pierre Hospital in Brussels already has performed about 65 operations with the da Vinci surgical system. Dr. Broeders co-ordinates the project "Operating Theatre of the Future" at the Utrecht Hospital, where the first robotic surgeries are planned next spring.

Together with the experimental cardiologist, Professor Dr. Kees Borst, Dr. Ivo Broeders aims at using the computer-enhanced minimally invasive surgery system to perform key-hole cardiac surgery without the heart-lung machine. Only a robotic arm is able to execute the subtle movements, needed to stitch blood-vessels during bypass surgery on a beating heart. The first key-hole cardiac surgery experiments with robots are very promising but the ultimate key-hole surgery on a beating heart still has to be performed. Dr. Broeders expects that the innovative robot technology will prove its high value in heart surgery first. The compactness of the thorax makes it rather unsuitable for conventional endoscopic interventions whereas surgeons need a more refined approach than cutting the patient's chest.

Dr. Broeders and Dr. Cadière already anticipate that within five years all major cardiac centres will have robots in the operating theatre. In general surgery, this will take five years longer because traditional laparoscopy offers an excellent and less expensive alternative. Nonetheless, the robotic systems facilitate laparoscopic interventions. The question remains whether surgeons are willing to experiment with computer-enhanced surgery in speciality areas where strong traditional methods have proven their reliability. There are also a few psychological drawbacks. The surgeon, always figuring as the centre of the operating room, now is banished from the scene. The patient seems to be reduced to the object of a video game, watched over by the assistant-surgeon and the nursing personnel.

Computer-aided surgery is being pushed tremendously by the industry. Dr. Cadière sometimes has to refrain himself from using it instead of a more suitable traditional method. The technology still has to be improved. In the meanwhile, robot applications for brain surgery are being developed. Dr. Ir. Kees Grimbergen, professor of medical technology at the University Medical Centre in Amsterdam, has set up a European project with Fokker Control Systems to design the Roboscope, a robot arm for brain operations. This technique allows to mark out the contours of a tumour using sensors based on pre-programmed data. The robot movement is blocked each time the surgeon reaches the boundaries of the tumour.

Dr. Grimbergen stresses that the surgeon needs landmarks for the system to know where the instruments are located since the organ shapes can change surprisingly during the intervention. This is especially true for the dynamic tissues in the abdomen. In principle, robots are able to automatically cut a tumour out of the brain without any help from the surgeon. For soft tissues, this is out of the question, according to Dr. Broeders. Robots also are used in hip replacement surgery. More and more complex interventions are being planned and trained in a virtual environment, based on digital images from Computed Tomography (CT) and Magnetic Resonance Imaging (MRI) scans of the operative field. The future generation of surgeons will surely have grown up with the PlayStation.

We have used de Volkskrant as our major source for this article on surgical robot systems. You can read more news about the computer-enhanced da Vinci system in the VMW Magazine articles European surgeons to experiment with minimally invasive procedures, which appeared in August 1998 and Small incisions, big results with Intuitive Surgical's da Vinci system, published in October 1999.

Leslie Versweyveld

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