Computer-assisted robotic cholecystectomy

Minimally invasive techniques have revolutionized operative surgery. In gastrointestinal surgery, the robotic system is applied to a wide range of procedures. Cholecystectomy, Nissen fundoplication and Heller myotomy are among the most frequently performed procedures. Most studies reported that robotic gastrointestinal surgery is feasible and safe, provides improved dexterity, better visualization, reduced fatigue and high levels of precision when compared to conventional laparoscopic surgery, but costs are high. This video shows a robotic-assisted cholecystectomy performed in teleconference with India. It is a very interesting video that makes us reflect how many could be the possible future applications of computer-assisted robotic surgery.

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Computer-assisted   robotic   cholecystectomy

Authors
J Leroy, M Smith-Savu, J Marescaux
Abstract
Minimally invasive techniques have revolutionized operative surgery. In gastrointestinal surgery, the robotic system is applied to a wide range of procedures. Cholecystectomy, Nissen fundoplication and Heller myotomy are among the most frequently performed procedures. Most studies reported that robotic gastrointestinal surgery is feasible and safe, provides improved dexterity, better visualization, reduced fatigue and high levels of precision when compared to conventional laparoscopic surgery, but costs are high. This video shows a robotic-assisted cholecystectomy performed in teleconference with India. It is a very interesting video that makes us reflect how many could be the possible future applications of computer-assisted robotic surgery.
Classification
robotic
Keywords
operation,robotic,Zeus,transatlantic,Lindbergh
Media type
Duration
17'00''
Publication
2005-09
Popular
Favorites
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Audio
en
Subtitles
en
E-publication
WeBSurg.com, Sept 2005;5(09).
URL: http://www.websurg.com/doi-vd01en1093e.htm

Computer-assisted   robotic   cholecystectomy

1. Case demonstration 00'17''
The arms for the camera are on the right side of the patient at shoulder level. To operate, both arms are positioned on the left side of the patient, one at shoulder level, the other on the lateral side as you can see. I have drawn 2 lines, one vertical: the midline, and one horizontal at umbilical level. Usually the body of the gallbladder is located here in the right subcostal area. It’s better for us to use this position. Maybe it’s less esthetic but you see that we use a 10mm, then 12mm port. We can also use a 5, or 3mm port. We will use a 10mm scope. So first we introduce the ports through open laparoscopy because we have to dissect the muscles. It’s a transrectal approach. Remember that after we have insufflated, we measure a distance not too close from the port otherwise you’ll have a conflict with your instruments, at a 7cm distance. Why? If you operate around the umbilicus, you’ll have a 10cm distance if you position your instruments here, closer, it’s 7cm. it’s important to keep the same angle at the tip of your instruments. If you’re very close to your operative field, you have to reduce the distance between the ports but you have the same angulation between your ports. It’s the 1st basic rule you have to know to avoid conflict with your instruments. We usually do an exploration of the abdominal cavity to see if there is no complication. This is a pseudo open approach: the size of the incision is the same than the size of the ports. You can use a suture to have an orthostatic exposure of the right subhepatic area. There’s no complete suspension of the ligament but it’s be better to introduce the instrument under the round ligament. This port will be used to retract the gallbladder. I have to introduce the last port to operate. So we use 4 ports. We have to respect the protocol determined by the FDA. I have 2 screens, one for the operative field (inside picture), and one outside picture if I want to operate far from the patient, and another screen to scale the possibilities of my instrument. I have also 2 handles. There’s one scale for instrument adjustment and selection of instrument type. I will show you how I can manipulate this camera. This is the Aesop system. Now I will choose different positions and put them in memory mode. I will ask the voice-controlled robotic arm to go from one position to another and stop in between. Can you explain what the foot pedals are being used for? If I don’t push this pedal, the system stops automatically. If I manipulate this, there’s no action inside. As you can see, I do nothing and the gallbladder stays into position. I have to push the pedal to be able to manipulate. Now I’m completing the dissection of Calot’s triangle and the artery as well. As you can see with the inside view, I operate with one instrument only. The other instrument holds the gallbladder. I can leave it in this position and can operate with one hand. In the future, you can also imagine that I’ll manipulate with orthostatic exposure different arms that expose and operate at a distance with the robot. An MRCP is performed because we have a doubt. This patient is young and if there’s a small common bile duct, we don’t perform the exploration if there’s no doubt. The handle you’re using reminds us of a joystick. Is it similar to it? Do you think that the robot will increase the ability of surgeons to do advanced laparoscopic surgery? Do you think it will make it easier for the surgeon to do surgery? It depends. Here it is a tele-manipulator. If you’re not a skilled surgeon, you won’t be skilled with the robot. What may be difficult to do then? With sutures, we have to move the needle and determine which part of the needle will enter on one side and exit another. It’s sometimes difficult to perform. If I had to push a button and ask the needle from one side to the other, automatically it’s a new tool. But in all hands, it’d be difficult. This kind of tool would make it easier not to make the suture but manipulate the needle and place it in a correct position. Engineers try to reproduce the surgeon’s abilities. Have you had any experience with the DaVinci system and if so, what do you think about it? They try to have an instrument that reproduces exactly what the hand or the finger of the surgeon is able to do. The argument is to use also 3D pictures. The problem is not to have an instrument that reproduces what I do only, but the problem that we face is similar to the one we encounter when doing mechanical and hand-made sutures. We increase the possibility of the surgery in a lot of hands not only in the hands of experts to do low colorectal or colo-anal anastomoses. I introduce it this way into the bag. Remember that I have used 5mm ports and I’ll show you how we remove the specimen. We remain in the same port axis and direction and we push the plastic bag and pull on the port progressively and we are outside of the abdominal cavity. So we use only a 10mm port. We can use a 3mm port or no port, using only the instrument as for children. Will it make it easier for the new surgeons to suture with this technology? Yes, but when you begin to do sutures by laparotomy, you’ve to train; it’s not easy, you have to learn the tricks. People understand that it’s new technology in that you just can’t use it, you can just have it and then use it, but you need to train just like regular surgeons and most people are probably very happy that they still would be a surgeon. You need a surgeon to operate the robot.