Indispensable innovations within 5 years
Two systems are commercially available, the Da Vinci from Intuitive Surgical and the Zeus system from Computer motion (Goleta, CA, USA). Since we do not have experience with the Zeus system, our discussion will be related solely to the use of the Da Vinci system.The input system i.e. the imaging system as well as all the afferences to the surgeon and the output system including the final surgical actions are now mediated by a new technology commonly called robotics. This is a genuine revolution, but in 2002, we are still just at the dawn of a new era. There are arguments that indicate that this invention might trigger a commotion within the surgical community comparable to the introduction of the Ford T in the automobile sector. We now have to improve the system in order to make our “Ford T” look like a car of to-day. The improvements concern 1/ the technology itself, 2/the codification of the surgical procedures and 3/the social organization around this new technology.
- The technology: regarding the afferences, the ideal optical system must of course provide a three dimensional image. At the present time, in order to restitute the three dimensional image, the optical system needs to be placed at too close a distance from the operative field which leads to frequent changes in the angle of view. A system must be designed to restitute a wider view, the ultimate aim being a three-dimensional high definition television picture which combines adequate 3 D perception with visual acuity. In addition, the fact that the actual visual input to the surgeon takes place from a remote point (video screen), technically permits integration of additional information. Indeed, the power of computerized graphics can be used to display digitalized pictures that can be overlaid, super impressed (or mixed) with the actual "real time pictures" from the operative field on the video screen. Three-dimensional pictures can be obtained by MRI or by Ct-scan, which can be super impressed and thus compared with the actual three-dimensional operative view. The following improvements can be anticipated: reduction of the size of the trocars from 8 mm to 5 mm, reduction of the bulk of the robot which so far takes a large place in the operating theatre, return of tactile sensation, and addition of an articulation inside the abdomen in order to resolve the problem of crowding at the robot arms. This is a specific problem in abdominal surgery where more amplitude of movements is needed to cover an intra peritoneal field. One can imagine a tool looking like a Swiss knife at the tip of an instrument which would avoid continuous tool changes and which would offer more autonomy for the surgeon. This will enable him/her to control him/herself the suction and to tackle a surgical bleeding. Once the problem of “arms crowding” solved, one can consider an additional articulating arm controlled by the surgeon at the console
- The standardized codification of the procedures has to be reinvented. Trocars placement must take into account the volume of the articulating arm and the presence of an articulation inside the abdomen.
- This new technology implies a new social organization. There is now need for a new individual dedicated exclusively to the well functioning of the robot during the procedure. We chose to call this person a clinical technician. This person needs a clinical as well as a technical background. His/her competence is the determinant factor in operative time and safety of the procedure. The surgeon has to accept the consequences of performing the procedure at distance of the patient and must rely more on technology.
We have to resolve all these challenges in order for robotics to be more beneficial in a greater range of laparoscopic procedures and to be introduced in our everyday general surgical practice.