In recent years, Robot-assisted Surgery, or Robotic Surgery is increasingly replacing traditional, open-incisional surgery, or even minimally-invasive equivalents such as Laparoscopy. With increased adoption in the coming years, Robotic surgery will overcome the cost barrier, and in a decade or two, most surgeries will be Robotic. In this article, we will discuss why and how Robotic Surgery is superior to Laparoscopic procedures.
There are umpteen ailments, diseases, disorders, syndromes or conditions where medication and alternate therapies may not work. In such a case, surgery becomes the final, inevitable option. Surgical procedures are of broadly three types:
An endoscope is a long, thin, flexible tube made of synthetic material. One end of the endoscope can be fitted with diagnostic equipment to investigate the condition. Endoscopes are extremely popular in diagnostic tests. As a natural evolution of this approach, laparoscopes were introduced to achieve surgical interventions. Here, endoscopes are fitted with camera, lens and light, just like in a normal endoscope. Further, they have stiff, stick like attachments that carry surgical instruments at the tip.
Once the patient is admitted into the OR, and sedated, the doctor makes small incisions around 5 centimetres long, on the skin, in the desired part of the body. While one incision is required to insert the scope with camera-light-lens fitment, one or more incisions are required to introduce scopes with the desired surgical attachments.
The camera-light-lens fitment relays images on to a computer screen kept in the OR. By looking at the same, the surgeon(s) can push the scopes around till they reach the exact spot. Thereafter, using the surgical attachments in the scopes, they can carry out the desired intervention.
Given the stiff, stick-like nature of the short arm-attachments, the surgeon’s range of motion is limited. Further, the cameras used are simple and compact, and they can only generate 2D images. It takes several years of practice, and skill to develop the ability to perform precise laparoscopic procedures. The surgeon must be physically involved in the procedure from start to finish. This leads to fatigue for him/her, not to mention shake and tremor in his/her hands. These are the primary disadvantages of laparoscopic surgeries.
However, Laparoscopy comes with the advantage of lesser cost compared to open-incisional surgery and robotic surgery, in most cases.
Given the drawbacks of Laparoscopy, they can be used only in some surgeries where complex manoeuvres are not required, and the intervention is fairly simple and straightforward. For example, they are used to diagnose several conditions that affect the abdomen or pelvis. They can also be used to carry out simple surgical procedures, such as removing a diseased or damaged organ or gland, or extracting a tissue sample for further examination.
However, there are several surgical procedures such as prostate surgery, Nissen fundoplication, lung resection, hysterectomy, treatment of gynaecological cancers such as uterine, ovarian and endometrial cancers, etc, that require complex or delicate manoeuvres, to achieve the desired intervention. The limited range of motion or flexibility available in a Laparoscopy becomes a drawback. So, previously, surgeons would fall back on open-incisional surgery as the other option. However, we know that open surgery is not for everybody. Its drawbacks become a limitation for the elderly and those with co-morbidities.
Robot-assisted surgery emerged as a better, and the third option, around the 2000s. As adoption of robot-assisted surgeries started picking up, the robots became more and more sophisticated with newer players entering the market. One of the most popular robots today is the ‘da Vinci Surgical system’ manufactured by Sunnyvale-headquartered Intuitive Surgical. We have already covered this in an earlier blog.
The da Vinci system has a console with instrument panel. A surgeon sits on a chair in front of this console, and operates the robot using joystick or toggle-switch like controls. The robot has four or more arms. One of the arms carries the camera-light-lens fitment, while the other arms carry long, thin, pen-like fitments with surgical instruments at the tip. Two-centimetre-wide incisions are made on the body to introduce the camera arm and the surgical arms inside the body at the desired spot. Up to this point, the procedure is similar to that of a laparoscopy.
However, the robotic arms have wrists which makes it easy to bend the arm-tips and move them horizontally and vertically. Â The arms themselves can be moved over a large angle in all dimensions. Sophisticated controls in the arm tips can ensure a controlled, minute and precise intervention without any risk of tremor. Further, the cameras generate high-resolution 3D images. This gives a better depth perception to the surgeon, which minimizes trial-and-error moves that are common in Laparoscopy.
Robotic surgery showed lower conversion rates to open surgery in rectal cancer but longer operative times in a meta-analysis of randomised clinical trials. No difference was noted with respect to complications, length of hospitalisation or lymph node yield. Another systematic review showed lower conversion rates to open surgery, faster bowel recovery, better lymph node retrieval; however, complication rates, mortality, length of hospital stay, and blood loss were similar to laparoscopy.
Another RCT on ventral hernia repair showed robotic surgery had longer operative times and was costlier than laparoscopy. No difference was seen in pain, complications, or length of hospital stay.
It should be noted that most comparisons between these two techniques are short-term studies. Further long-term and multicentre trials are needed to realise the benefits of robotic surgery over laparoscopy.
Considering the advantages and disadvantages of robotic surgery, certain conditions make robotic surgery a preferable option, although even in these situations, the benefits have to be weighed against the cost of the procedure, logistics, as well as strong evidence.
Emerging technologies, such as augmented reality and virtual reality, have increased precision and safety by providing 3D visualisation of the patient’s anatomy. Natural orifice transluminal endoscopic surgery (NOTES) is a scarless surgery that uses the body’s natural openings to access the internal organs, reducing trauma and improving healing. Single-incision laparoscopy uses a single entry point that improves cosmetic outcomes, reduces pain, and lowers complication risks.
Compact instruments (allow delicate surgeries to be performed), haptic feedback (helps surgeons assess the tissues by restoring the sense of touch) and adaptive robotics (guides surgeons in real-time on their movements, improving efficiency) are showing promise in improving overall patient outcomes.
Not everyone is suited for an open surgery which is why laparoscopy emerged. In the same way, not all procedures are suited for a laparoscopy, so Robotic Surgery which is superior, emerged. However, not everyone is suited for Robotic surgery too. While cost is a barrier for some patients and some procedures, the age and BMI of the patient, and nature of the condition becomes a limitation sometimes.
That is why, the decision to use the best possible option is made by a panel of surgeons and case-doctors after doing required diagnostic tests and discussing various aspects of the case. Large hospitals offer all these benefits, which minimizes decision-making dilemmas for the patient. The patient can just sit back and enjoy the benefits of medical technology, while looking forward to effective treatment.
Kauvery Hospital is globally known for its multidisciplinary services at all its Centers of Excellence, and for its comprehensive, Avant-Grade technology, especially in diagnostics and remedial care in heart diseases, transplantation, vascular and neurosciences medicine. Located in the heart of Trichy (Tennur, Royal Road and Alexandria Road (Cantonment), Chennai (Alwarpet & Vadapalani), Hosur, Salem, Tirunelveli and Bengaluru, the hospital also renders adult and pediatric trauma care.
Chennai Alwarpet – 044 4000 6000 • Chennai Vadapalani – 044 4000 6000 • Trichy – Cantonment – 0431 4077777 • Trichy – Heartcity – 0431 4077777 • Trichy – Tennur – 0431 4022555 • Maa Kauvery Trichy – 0431 4077777 • Kauvery Cancer Institute, Trichy – 0431 4077777 • Hosur – 04344 272727 • Salem – 0427 2677777 • Tirunelveli – 0462 4006000 • Bengaluru – 080 6801 6801
