Robotic Surgery

From Dr John F. Dulemba

ROBOTIC SURGERY: 

I think it is time to explain the Davinci robot from the viewpoint of someone that actually uses the device. There are many people that may disagree with some of the things I will mention, or describe, but this is based on my published data, my experience, and my opinion. This explanation is related to endometriosis, adhesions, and pelvic pain. Before starting robot laparoscopy, I had completed over 3,500 standard laparoscopic cases for endometriosis, and was considered by many as an expert standard laparoscopic surgeon. I started using the Davinci robot in early 2007, but have been doing some form of robotics since 1997 (in 2001, a gallbladder was removed in Strasbourg, France, but the surgeon was in New York City). I now have over 1,400 endometriosis cases using the robot, and I think that may be the most endometriosis robotic cases by any single surgeon in the world. I only perform Davinci robotic laparoscopy, so, I think that enables me to compare both approaches to laparoscopy better than surgeons that have never used the robot, only have a few robotic cases, or still divide their cases between standard laparoscopy and robotic laparoscopy.

Robotic surgery is still just laparoscopy. That is the first hurdle that needs to be understood. There is nothing magical about the robot, but there are many benefits to robotic surgery in comparison to standard laparoscopy. Patients have stated that they did not want robotic surgery, because they wanted the surgeons hands “doing” the surgery. Even in laparoscopy, the surgeon does not touch the tissue with his hands. The surgeon uses instruments, and often the same type of instruments as standard laparoscopy, to perform the surgery.

A major difference is the comfort of the surgeon. With standard laparoscopy, the surgeon is standing next to the patient, and often has to reach across the patient to manipulate the instruments, and can be in uncomfortable positions for hours. I sit in a comfortable chair at a console with my arms resting on padded armrests. Why is resting the arms during surgery important besides fatigue factors? Try threading a needle with thread and have your arms extended. It makes the threading more difficult, because tiny movements may occur. The console adjusts to many positions for added comfort (ergonomics). In a long case, or cases, fatigue is less likely to occur from standing or reaching during that time. Physical fatigue may not seem like a big deal, but it can affect decision making and surgical skills. This is extremely important when dealing with hard and difficult endometriosis cases, such as dissecting around important organs and structures.

The movements of the instruments are “wristed”. This means that the instruments have actions of movements similar to the human wrist (520 degrees of rotation), and 7 degrees of freedom. What does that mean? That means there are areas of the robotic instrument arm that are similar to the human arm, such as the elbow. That way the instrument can move in different directions, bend, turn twist in ways that standard laparoscopic straight instruments cannot move. Standard laparoscopy instruments can still reach tissue, but more torque and pulling is needed to reach the desired positions. Try to imagine your arm in a cast, and trying to perform certain tasks. You can do it, but more difficult than if your arm does not have restricted movements. Then the instruments have “intuitive” movements. Again, what is that? With standard laparoscopy, if you move your hand to the right, your instrument will go to the left (counter-intuitive). To the left, the instrument goes to the right. With Davinci robotic surgery, when I move my hand to the right the instrument goes to the right. To the left, the instrument goes to the left. Another benefit is when I move the robotic instrument an inch, it moves an inch, or I can scale the movement so that if I move an inch the instrument will move 1/5th of an inch. The advantage in that is any tremors in the hand are minimized, and (in my opinion again) more accuracy when making movements, cuts, or dissection. I normally use scissors in my right hand, but a few times it was difficult to reach an area behind my scissors. I then switched the scissors to my left hand. I “swapped” control of the left hand so now the left hand scissors were controlled by the right hand. That way I was using the same hand I normally would cut with, but now n the left. That may be a little confusing, but a huge benefit to me. When I lift my head from the console viewer, my instruments lock into place. The benefit from this is that I can use an instrument to hold things out of the way, and that instrument will not move until I make it move. That is very important when retracting tissue away from the surgical field. If need be, I can add an extra arm/instrument. This would require an additional tiny incision but with a tap of my foot, I can toggle between two different types of instruments on one side, and one of the instruments can then be a retractor.

Visualizing endometriosis is so important when dealing with endometriosis. Why? It is a common thought that ANY amount of endometriosis may cause pain. If that is true, then all endometriosis needs to be seen, and then should be removed. Experts have the surgical skills to remove endometriosis, and they are aware of the different appearances of endometriosis. Most gynecologists are trained to look for the “powder burn” blue/black lesions. In my opinion, the greatest difference between standard laparoscopy and Davinci robotic surgery is the visualization. Davinci robot is 3D versus 2D for Standard laparoscopy, but both have HD visualization. For those that do not think there is a difference between 3D and 2D, then drive your automobile with one eye closed. If you drive like that all the time, then your one eye will adapt, but you can see better with two eyes. The surgical field is magnified 10 times, so all of the tissue and organs appear to be bigger, and “tissue planes” are more visible. This helps with dissection, excising endometriosis, and separating organs and adhesions. My published data, unpublished data, and other data from physicians have shown that more endometriosis can be visualized with the 3D and magnification. An appearance of endometriosis not visualized with 2D is “terrain changes”. Unless the surgeon actually uses 3D visualization, the changes in the surface of the tissue cannot be seen. Some doctors drip the patient’s blood across the surface of the tissue, or use a dye, to try and check for changes. Many doctors say you don’t need 3D, but if there is a chance they are not visualizing all of the endometriosis, then why are they dripping liquids to look for areas not seen with the 2D? There are some 3D cameras for standard laparoscopy, but the small movements of the hand held camera make the 3D difficult to use. It has been shown that when evaluating skills with new laparoscopic surgeons, there are significantly less errors when using 3D versus 2D, and the surprising outcome was that with expert laparoscopists, they also had significantly less errors when using 3D versus 2D. The camera with the robot is perfectly still, and only moves when I move it. This aspect is important when working around important structures, because you don’t want movement of the surgical field as you operate. I now find it difficult to watch surgery when someone is doing standard laparoscopy, because the small imperceptible movements now seem like huge movements to me after the stable robot camera. I almost get motion sickness watching the screen. Firefly is a function of the camera that changes the light filter so that abnormal blood vessels can be visualized using a special dye and green light. I have found that in early disease, the firefly enables me to see blood vessel changes consistent with endometriosis that is not seen in the normal spectrum of light. If any blood is present, then firefly is not useful.

There are negatives to the Davinci robot. A complaint is that there is a loss of tactile sense (touch and feel). Over time, the brain adapts, and the surgeon seems to develop a visual tactile sense. I can detect soft and hard tissue. The visual tactile sense allows me to be as gentle as normal hands and laparoscopic hands. Some surgeons say that you cannot put your hands in the vagina to feel for masses, well, all the surgeon has to do is stand up from the console, put on a pair of gloves, and do the exam. To use that one issue as a reason to not use robotic surgery does not make sense. There are often one to two more incisions than standard laparoscopy when using the robot, and the incisions need to be higher to get the full range of motion from the instruments. If cosmetic appearance of tiny incisions is more important than all of the listed benefits, then maybe standard laparoscopy is better for you. The cost of the hospital robotic surgery may be more expensive by $800-1,000 more than standard laparoscopy, but again, the benefits may make that cost worthwhile. Surgeons that go back and forth between standard laparoscopy and robot laparoscopy are not allowing their skills to develop completely for each approach. As robotic skills increase, there will be a decrease in standard laparoscopic skills. Movements that were second nature with standard laparoscopy are not the same movements with robotic laparoscopy, and so more thinking is needed to perform routine movements. To reach the highest level of skills in any area, repetition is needed, and not the confusion of opposite activities.

I have seen people saying the robot is just a tool, and I agree, but disagree. Using standard laparoscopy does not mean a surgeon is an expert in endometriosis, and on the same thought, a surgeon using the Davinci robot laparoscopy does not make them experts. I have heard patients state that “my doctor uses the robot”. That may increase their surgical skill level, but there are more aspects of treating endometriosis than just surgical skills. All of these positives and negatives of robotic surgery do not mean better outcomes, but the Davinci robot laparoscopic surgery is more accurate and precise than standard laparoscopy.