RoboDoc challenges surgeons to feel with their eyes at the University Hospital of Antwerp

Edegem 20 September 2002Seated at a console at a few meters distance from the operating table and watching a 3D electronic image of the patient's abdomen, Professor Surgeon Guy Hubens is manipulating two joysticks. His movements are translated into corresponding surgical actions by a robot. The patient has not been cut open for this gastro-intestinal surgery. Only through tiny incisions, the thin tube-like ends of the three robotic arms are entering the body. RoboDoc is invading the operating theatre. The American Da Vinci robot system allows to perform in an extremely flexible and accurate manner, a range of patient-friendly surgical interventions including complex bypass operations. The familiar advantages of keyhole surgery such as less injuries, faster recovery and reduced risk to incur complications, are combined with a precision which equals and even exceeds the results acquired in conventional surgery. Last May, the University Hospital of Antwerp (UZA) in Belgium started to use the new system as the first academic hospital in Flanders.

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For the past ten or fifteen years, abdominal surgeons in particular were able to help millions of patients worldwide by means of keyhole surgery. Flexible tubes are entered into the patient's body through tiny incisions in order to introduce into the operative field a mini-camera and surgical tools which are being manipulated by the surgeon's hands from the outside.

"This type of minimally invasive surgery has caused a revolution", stated Professor Hubens, Chief-Assistant in the Department of Abdominal and Paediatric Surgery at UZA. "Because of the tiny incisions, the operative trauma is minimised. The large injuries often due to classical abdominal surgery can easily cause pain or complications, such as wound infections or scarring, after the intervention, which may require repetitive surgery."

"For a number of relatively simple interventions like, for instance, gall bladder procedures, traditional keyhole surgery is very suitable, but for more complex surgery, it is not", explained Professor Hubens. "The reason is that the surgeon has to rely on a two-dimensional TV-image which has totally no perspective. In addition, the surgical tools that are put into the small flexible tubes offer only a limited freedom of motion."

Today, however, robotic surgery is taking surgery to the next level. Talking about the Da Vinci robot system which has passed the severe tests of the U.S. Food and Drug Administration, an FDA-representative stated: "This system is the first step in the development of a new robot technology which eventually will change the surgical practice." This change is about to happen now.

The Da Vinci robot system allows to combine the advantages of keyhole surgery and conventional open surgery. Flexible tubes are still being inserted into the patient's body but these are part of the three computer-aided robotic arms which are equipped with the surgical tools. The surgeon transmits his instructions to the computer, sitting behind a console instead of standing near the patient's body on the operating table. Two smart joysticks are connected electronically to the joint-like surgical tools which perform exactly the same actions as in open surgery. Since two cameras mounted side-by-side are introduced into the patient's body, the surgeon is able to permanently view a real 3D image of the operative field.

"As a surgeon, you experience little difference to an open surgery", stated Professor Hubens. "The surgeon's eyes and hands are at a similar distance from the operative field. The only difference is that you look at an electronic image while manipulating two joysticks instead of the instruments. The surgeon performs precisely the same actions as in conventional surgery since the joysticks and instruments are provided with an identical range of degrees of freedom as human hands have. In traditional keyhole surgery you have a different situation because the surgeon constantly has to move his eyes from his hands to a distant monitor and back again. The correspondance between eyes, hands, tools and patient organ is far from ideal in this context", added Professor Hubens.

"The interesting thing about a robot system is that the monitor in the console magnifies the operative field up to fifteen times. The surgeon thus gets a far better view of what he is doing than when he is standing at the operating table." This allows the surgeon to work more precisely than in open surgery while the patient incurs less operational injury. The system also enables the surgeon to downscale the movements of his hands to perform the procedure more accurately. A 5mm movement with the hand can for instance be translated into a 1mm movement at the instruments' level. This facilitates the delicate part of the work and allows to compensate any possible trembling of the surgeon's hand.

A wide range of safety provisions has been built into the system. "The patient does not have to fear. The robot arms cannot run out of control since they only start moving on the surgeon's request. As soon as the surgeon's hands perform an abnormal action in a particular procedure's context, the entire system immediately is blocked", explained Professor Hubens.

The Da Vinci robot system offers new perspectives in tele-surgery since no direct contact is required between surgeon and patient during an operation. "A surgeon in Antwerp can for instance perform a procedure on a patient in the United States or China provided that there is a good connection to transmit images and instructions efficiently", commented Professor Hubens. "In that respect, the concept of robot surgery was born in the U.S. Army where one does not like to send highly qualified surgeons to dangerous regions. Instead, valuable medical know how is stationed in a safe place and procedures are being performed from a distance."

The robot system is working excellent but still lacks perfection in the sense of haptic feedback. "As a surgeon, you miss the tactile sensation, you do not feel how resistant or elastic the tissue or organ is when inserting instruments into it, you do not experience any pressure at all. According to the engineers who developed the system, the problem can be solved but only at a very high cost. I don't know wheter that extra cost would be justifiable given the fact that the longer you work with the system the better you succeed in compensating the lack of haptic feedback with visual information. You learn to feel with your eyes", as Professor Hubens stated.

Despite the investment of $1 million excluding the costs for use and maintenance of the equipment and for training of the surgeons, the acquisition of the robot system by the University Hospital of Antwerp seems also financially justified. "Our university hospital has a responsibility to validate the clinical and economical added value which new technologies can bring", explained Dr. Hubens. "As a specialised and scientifically oriented institution, UZA plays an important role in helping to determine for which procedures the robot system is suitable and to make suggestions for adjustments which can reduce the overall cost. At present, some hundred Da Vinci robot systems are operational worldwide, but UZA is the first university hospital in Flanders where the system is officially used."

"The amount of days or weeks the patient has to stay in the hospital has been reduced drastically. Traditional open gall bladder surgery requires a hospital stay of seven to ten days compared to barely two or three days when the robot is used. For complicated procedures on organs like stomach or esophagus, we hope to bring back the hospital stay from three or four weeks to one or two weeks. Combined with the smaller risk for complications in keyhole surgery, the shorter stays will result in substantial savings for the medical insurers", Professor Hubens continued.

"Apart from abdominal surgery, the new system can also be applied in a wide range of procedures which allows to spread the fixed costs. Within the UZA, a robotics group has been set up to manage robot use for broader applications. In urology for instance, the system has been utilised for a complete removal of the prostate. We also use the system in hepato-biliar surgery, lung surgery and gynaecology. In the near future, cardiac surgeons will apply the robot in bypass operations. Is it not a fantastic accomplishment that we no longer need to saw through the chest bone nor open the entire patient's thorax to repair arterial obstructions but that the procedure can be performed via three incisions of 1cm?" Professor Hubens stated.

From a medical viewpoint and taken into account the welfare of the patients, especially of those who have to undergo a complex procedure which cannot be performed through conventional keyhole surgery, the Da Vinci robot system is definitely a major breakthrough. However, it is not a universal solution.

"Just like in traditional keyhole surgery, also in robot surgery, a little bit of gas has to be introduced into the patient's body near the operative field to create a sufficient amount of space for the surgical instruments. If however a patient has been operated before in the same spot, the presence of scarred tissue and deformations can be a hindrance to create that space. In this case, keyhole nor robot surgery are applicable", explained Dr. Hubens. "The robot system is neither adapted to organ transplantations. To replace a heart or a kidney, it is necessary to make a big incision. We do not know either whether the system can be used in a safe way to operate on cancer patients, although we believe it could be possible. We are still in the phase of research for this type of surgery."

The advance of digital technology in surgery has changed the surgeon's role. "A surgeon not only has to have a good knowledge of anatomy, physiology and the classical surgery procedures but also has to be a computer savvy in order to act as a troubleshooter whenever a problem arises in using the robot equipment. Who knows whether in the future, the surgeon will be assisted in the operating theatre by a medical engineer, a person who has a basic medical knowledge as well as a profound technical insight with regard to the equipment", concluded Dr. Hubens.

"The surgeon's task will not be overtaken by the computer or the robot. We still have to perform the job ourselves. The technology will only support the surgeon in making a number of procedures more patient-friendly. Medical technology is evolving at such a rapid pace that no one can predict how surgery will develop in five to ten years from now. Where this will lead to is barely conceivable."

More news on the robot system at UZA is available in the VMW June 2002 article University Hospital of Antwerp to invest in joystick surgery for minimally invasive procedures.


Leslie Versweyveld

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