Clinical Laparoscopic Experience up to 2002
Each procedure has its own characteristics. It appeared worthwhile to analyze some of the most common ones as they are approached by the robot.Since 1997 up to 2002 the following laparoscopic interventions have been performed with robot technology:
- Anti-reflux surgery
- Appendectomy
- Cholecystectomy
- Deferent duct reanastomosis
- Endometriosis eradication
- Gastroplasty
- Hysterectomy
- Inguinal hernia
- Intrarectal procedure
- Lumbar sympathectomy
- Neosalpingostomy
- Gastrectomy
- Oesophagectomy
- Pyeloplasty
- Prostatectomy
- Tubar reanastomosis
- Varicocele ligation
Concerning the Nissen procedure : the operative time compares favorably with the laparoscopic procedure. We experienced substantial advantage from the articulated tools while dissecting behind and around the esophagus. Hence it might be possible to consider for the future less extended a dissection at the level of the peritoneal attachments of the stomach’s cardia. This might render the procedure easier and more resembling to the open, conventional operation. Another step of the operation where the tools’ articulations proved beneficial was the dissection of the short gastric vessels. Suturing the wrap appeared more straightforward, as it is easier to follow the curve of the needle while driving the suture through the tissues. We experienced a net improvement in tying the knots, thanks to the articulated tools. The evaluation of the knots’ tension is however more difficult, because there is no tactile feed back. The theoretical advantage brought by the downscaling ability did not ad a substantial benefit in the fundoplication as compared with the laparoscopic technique. However, we did experience a significant drawback of the robot system in its present embodiment. As the three dimensional optical system is characterized by a very narrow field of vision, we continuously had to interrupt the dissection for optics repositioning . These frequent interruptions, as well as the absence of a general view of the operative field might be responsible of the bleeding we encountered while dissecting the greater curvature with the robotic system. This bleeding necessitated conversion into a conventional laparoscopic approach.
In cholecystectomy, we had to change the conventional position of the trocars in order to accommodate the robot arms. We experienced significant benefit from the articulated coagulating hook in dissecting the anterior and posterior peritoneal sheet at the level of Callot’s triangle. We experienced similar benefit in dissecting the cystic duct and artery . The cystic duct could easily be ligated rather than clipped, just like in open surgery. The operative time depended merely on the degree of inflammation we encountered. However, we do believe that the robot did help us in the cases of acute cholecystitis, and the operative time tended to go down as experience was gained.
In Fallopian tube reanastomosis the golden standard is still the open, microsurgical approach because the laparoscopic approach does not allow adequate micro suturing. In the robotic technique, however, operative time for the anastomosis is comparable to the gold standard, while hospital stay seems to be reduced.. With the computer enhancement and downscaling, suturing becomes more straightforward and more precise. The surgeon can rest his hands and since all tremor is eliminated by the computer interface suturing is extremely accurate which results in excellent clinical results
In obesity surgery, it is difficult to manipulate the instruments as the thickness of the patient’s body wall impairs the mobility of trocars and ancillary tools. The root driven articulated instruments deal well with this condition. The problems of ergonomics encountered with the massively obese are obviously solved by placing the surgeon at a working console at a distance. However, in case of a local hemorrhage, the surgeon cannot intervene and must rely on the skills of the assistant in order to control it. This new situation can be extremely frustrating for the surgeon.
In retroperitoneal procedures The new system was used as well (retroperitoneal lumbar sympathectomy, preperitoneal inguinal hernioplasty). This demonstrated the possibility to benefit from computer enhancement even in very confined working spaces. Relatively complicated tasks like dissecting the minuscule rami communicantes in the close neighborhood of the large abdominal vessels were successfully achieved without problems.
In transanal intrarectal procedures, the surgical tools are very tangential with the lesion. With the Da Vinci system the three dimensional image, together with the fully mobile articulations brings every millimeter of this small cavity within reach and at a 90 degree angle of approach. Fingertip motions are accurately repeated by the robot arms. The drawback in this approach is the relative bulk of the instruments and the optical system that need to be introduced transanally.
In oesophagectomy, the wide operative field is a continuous problem for the management of the surgical cart. However the dissection of the intra- thoracic part of the esophagus by thoracoscopic approach causes less trauma in the intercostal space because of reduced motions of the trocars thanks to the improved freedom of motion of the intracavitary articulated tools.
In general, for the laparoscopic procedures mentioned we did not encounter specific system related morbidity. Operating time and hospital stay were within acceptable limits. The system appeared most beneficial in intra-abdominal microsurgery and for manipulations in a very small space. Optimized ergonomics and increased mobility of the instrument tips proved advantageous in a few selected steps of abdominal surgical procedures.
The procedures in which the system is the most efficient are tubar reanastomosis, intra-rectal procedures, but also, considering our clinical experience, intra-thoracic dissection of the esophagus (16,17,18).We can summarize the current challenges of Robotics as follows: the operating field with the currently available scope is smaller than with conventional laparoscopic optics. There is no tactile feed back. The set-up and tool change require extensive team training. Team cohesion is of the utmost importance as surgeon-assistant interaction is essential, especially in case of haemorrhage or other peroperative mishaps. The cost issue must be revaluated once more widespread use of robotic systems has been achieved.