Japanese Journal of Clinical Oncology 34:227-237 (2004)
© 2004 Foundation for Promotion of Cancer Research
Robotic Surgery and Cancer: the Present State, Problems and Future Vision
1 Department of Disaster and Emergency Medicine, Graduate School of Medical Sciences and 2 Center for Integration of Advanced Medicine, Life Science and Innovative Technology (CAMIT), Kyushu University, Fukuoka, Japan
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ABSTRACT |
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 TOP ABSTRACT INTRODUCTIONNAVIGATION SYSTEMSSURGICAL ROBOTSROBOTIC SURGERY FOR TUMORS...PROBLEMSTHE FUTURECONCLUSIONSREFERENCES |
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In the 1990s, laparoscopic surgery entirely changed the traditional style of surgical operations. Laparoscopic cholecystectomy has spread rapidly and is now established as the standard treatment. However, besides cholecystectomy, endoscopic procedures are still not applied so widely to a variety of surgical operations. This is because laparoscopic techniques, such as suturing or ligation, make it difficult for surgeons to perform other kinds of operations and thus greatly increase their mental and physical stress. It is necessary to introduce various advanced technologies such as: surgical robots, three dimensional (3D) images, computer graphics (CG), computer simulation technology and others. Surgical robots, including the AESOP, da Vinci and ZEUS systems, provide surgeons with technologically advanced vision and hand skills. As a result, such systems are expected to revolutionize the field of surgery. However, there have so far been few studies which discuss the indications of robotic surgery for tumors/cancer. Therefore, herein we review various studies published in English to focus on the application of robotic surgery to tumors/cancer.
We point out that there are several problems to be solved for robot surgery: i) price of surgical robots, ii) training systems for surgeon, iii) coverage by medical insurance, iv) downsizing and v) navigation system. In conclusion, we believe that, in the near future as robotic technology continues to develop, almost all kinds of endoscopic surgery will be performed by this technology. It will replace traditional surgery not only in the treatment of benign diseases but also in malignant illnesses.
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INTRODUCTION |
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TOPABSTRACTINTRODUCTIONNAVIGATION SYSTEMSSURGICAL ROBOTSROBOTIC SURGERY FOR TUMORS...PROBLEMSTHE FUTURECONCLUSIONSREFERENCES |
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In the 1990s, laparoscopic surgery entirely changed the style of surgical operations. The popularity of the laparoscopic cholecystectomy has spread rapidly and it has now become the standard treatment for cholelithiasis. However, the technique has not spread much beyond cholecystectomy, because laparoscopic techniques, such as suturing or ligation, make it difficult for surgeons to perform other kinds of operations, thereby greatly increasing their mental and physical stress. Basically, surgical operations have been developed over the years based on the surgeon’s skillful hands and trained eyes.
However, to develop new surgical therapies in the 21st century, it is now necessary to adopt various advanced computer-enhanced technologies; such as surgical robots, three dimensional (3D) images, computer graphics (CG), computer simulation technology and others. 3D images for surgical operations provide surgeons with advanced vision.
Surgical robots, such as AESOP (1–4), da Vinci (5,6) and ZEUS (1–4,7), provide surgeons with technologically advanced vision and hand techniques, which have revolutionized surgery in various fields (see Tables 1–6). The advanced vision and hand techniques now available to surgeons are leading to the development of new surgical fields such as minimally invasive surgery (MIS), non-invasive surgery, virtual reality micro-surgery, tele-surgery, fetal surgery, neuro-informatic surgery and others (8,9).
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However, so far there have been few reports which have discussed indications of robotic surgery in the treatment of tumors and cancers. We therefore review here the previous literature to discuss the use of robotic surgery in the field of cancer therapy.
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NAVIGATION SYSTEMS |
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TOPABSTRACTINTRODUCTIONNAVIGATION SYSTEMSSURGICAL ROBOTSROBOTIC SURGERY FOR TUMORS...PROBLEMSTHE FUTURECONCLUSIONSREFERENCES |
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In many surgical fields, including craniomaxillofacial surgery, computer-aided surgery (CAS) based on computed tomography (CT) data is becoming increasingly important. Navigation systems, which allow precise intraoperative orientation of surgical instruments, can be used for greater accuracy in determining the resection margins of target lesions. These techniques also greatly support ablative procedures. However, more complex procedures, such as reconstruction, still remain a problem. Therefore, a computer-aided design (CAD) and computer-aided manufacturing (CAM) system has been developed which allows the construction and fabrication of individual templates for resections based on coherent numerical 3D models (10–12). Iseki and co-workers developed an overlaid three-dimensional image-guided navigation system in neurosurgery, which is able to navigate surgeons accurately during operative procedures (13–15).
In addition, the combination of surgical robots and navigation systems using CT (16), MRI (17) and US (18) will allow us to perform more precise and more minimally invasive gene therapy (e.g. local injection).
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SURGICAL ROBOTS |
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TOPABSTRACTINTRODUCTIONNAVIGATION SYSTEMSSURGICAL ROBOTSROBOTIC SURGERY FOR TUMORS...PROBLEMSTHE FUTURECONCLUSIONSREFERENCES |
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The Master–Slave Manipulator
In general, robotic systems consist of three parts: a surgical cart, a vision cart and the surgeon’s console. The surgeon sits at a control console equipped with a display that presents images obtained with an endoscopic camera inside the patient’s body. The surgeon’s console also provides master manipulators, which the surgeon can use to control the movements of the corresponding surgical or patient-side manipulators (slave manipulator) that hold the surgical instruments and the endoscopic manipulator used for the procedure. The surgeon looks down into the viewer as if looking into the surgical field and at his hands. He holds on to the control handles with his left and right hands. He then carefully guides the tool tips inside the patient’s body. As the surgeon moves the manipulators on the surgeon’s console, the patient-side manipulators closely follow the input motions.
This master–slave manipulator allows surgeons to perform more precise surgical procedures than those available in conventional endoscopic surgery. A previous study showed that remote-access endoscopic telemanipulation can successfully achieve complex 3D manipulations and the intuitive orientation of the surgeon’s workstation may also make such tasks easier to complete (19).
AESOP®
The first robot approved by the US Food and Drug Administration (FDA) for clinical use in the abdomen was the automated endoscope system for optimal positioning (AESOP) (Computer Motion, Goleta, CA). At the time it was first introduced, the surgeon controlled the robotic arm either manually or remotely with a foot switch or hand control (1,2), but the most recent generation of AESOP is voice controlled (3,4).
da VinciTM
The da VinciTM Surgical System was developed by Intuitive Surgical (Mountain View, CA). So far, 196 da Vinci systems have been installed worldwide. Many kinds of surgical operations, such as general surgery, urology, cardiothoracic surgery and pediatric surgery, have already been performed using the da Vinci system (see Tables 1–6). This system consists of three main parts: (i) The Surgeon Console, which is controlled by the surgeon: (ii) the Surgical Cart, of which three arms directly perform the procedures; and (iii) the Vision System (Fig. 1). The computer system which controls the whole system resides in the Surgeon Console (5,6). The notable features of the da Vinci Surgical System are as follows: the surgical instruments with the Endo WristTM move like human hand motion by artificial articulation and the visualization through a high-quality 3D endoscope is optimal.
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This system provides surgeons with (i) an intuitive translation of the instrument handle to the tip movement, thus eliminating the mirror-image effect, (ii) scaling, (iii) tremor filtering, (iv) coaxial alignment of the eyes, hand and tooltip image and (v) an internal articulated endoscopic wrist providing an additional three degrees of freedom.
Regarding the treatment of tumors and cancer, we have successfully performed robotic surgery for esophageal tumors, thymoma, retromediastinal tumor, gastric cancer and colon cancer using the da Vinci (6).
ZEUS®
Computer Motion, the manufacturer of AESOP®, has also developed the ZEUS® telerobot (7) (Fig. 2). It used AESOP as the foundation for the development of a robot capable of telerobotic surgery. In this system, the voice-controlled robot, AESOP, continues to hold the camera. Two additional AESOP-like units have been modified to hold surgical instruments. The ZEUS system provides almost the same function as the da Vinci, except for the internal articulated endoscopic wrist. Furthermore, ZEUS enables surgeons to perform long-distance remote control surgery using SOCRATESTM (Computer Motion). SOCRATESTM is a surgical telecollaboration system that links remote surgeons directly with colleagues in the operating room. HERMES® (Computer Motion) is the leading-edge operating room’s central nervous system. HERMES® enables the surgeon and staff to control a wide variety of networks consisting of AESOP®, ZEUS® and SOCRATESTM.
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NaviotTM
A new system has also been developed recently in Japan called the laparoscope manipulator, NaviotTM (Hitachi, Tokyo, Japan) (20–22) (Fig. 3). This system is recognized as the first surgical robot ever developed in Japan. This manipulator is based on a five-bar linkage mechanism that has two independent motors on the bottom. In addition, the zoom-up mechanism of the laparoscope was applied to this manipulation system. The moving range was about 25° in both the vertical and horizontal directions. As of March 2004, we had performed laparoscopic surgery on 100 patients using this Naviot.
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Comparison between da Vinci and ZEUS
At present, according to two evaluation studies (23,24), the da Vinci system is considered to have some advantages over the ZEUS system.
In an animal study by Sung and Gill (23), during a laparoscopic nephrectomy, the da Vinci system had a significantly shorter total operating room time (51.3 versus 71.6 min; P = 0.02) and actual surgical time (42.1 versus 61.4 min; P = 0.03) compared with the ZEUS system. For a laparoscopic adrenalectomy, the da Vinci system (n = 5) had a shorter actual surgical time (12.2 versus 26.0 min; P = 0.006) than did the ZEUS system. For laparoscopic pyeloplasty, the da Vinci system had a shorter total operating room time (61.4 versus 83.4 min; P = 0.10) and anastomotic time (44.7 versus 66.4 min; P = 0.11). During pyeloplasty anastomosis, the total number of suture bites per ureter was 13.0 for the da Vinci system and 10.8 for the ZEUS system.
In a study by Dakin and Gagner (24), 18 surgeons performed tasks in a training box using three different instrument systems: standard laparoscopic instruments, the ZEUS Robotic Surgical System and the da Vinci Surgical System. The basic tasks included running a 100 cm rope, placing beads on pins and dropping cotton peanuts into cylinders; fine tasks included intracorporeal knot tying and running stitches with 4–0, 6–0 and 7–0 sutures. The time (in seconds) required and precision (number of errors) in performing each task were recorded. Standard instruments performed significantly faster than either robotic system on the rope and bead tasks (P < 0.05), whereas da Vinci performed significantly faster than ZEUS in all three basic tasks (P < 0.05). No significant difference in precision was found between the standard instruments and the robotic systems regarding any of the basic tasks. Knot tying and the running suture time were similar between the standard instruments and da Vinci, which were significantly faster than ZEUS (P < 0.05) for all suture sizes. The robotic systems showed a similar precision for fine suturing tasks and they were also significantly more precise in knot tying (ZEUS and da Vinci) and running sutures (da Vinci) than standard instruments (P < 0.05).
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ROBOTIC SURGERY FOR TUMORS AND CANCERS |
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TOPABSTRACTINTRODUCTIONNAVIGATION SYSTEMSSURGICAL ROBOTSROBOTIC SURGERY FOR TUMORS...PROBLEMSTHE FUTURECONCLUSIONSREFERENCES |
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Neurosurgery
Neurosurgery is the pioneer and the most active field in robotic surgery. Lunsford reported for the first time the introduction of the gamma knife for brain surgery without making an incision (25). According to this study, the gamma knife was approved for marketing by the FDA in 1982 and the device received approval of the Nuclear Regulatory Commission (NRC) in 1986. Finally, this gamma knife device was first used for patient treatment in 1987 in Pittsburgh, PA (25) and due to this first step, the concept ‘brain surgery without an incision’ is now a reality.
Drake et al. performed a computer- and robot-assisted resection of thalamic astrocytomas in children (26). Six children ranging in age from 2 to 10 years who had deep benign astrocytomas were operated on using a robot-assisted system and a radical excision was achieved. This system consists of an interactive 3D display of CT image contours and digitized cerebral angiograms which were taken using the Brown–Roberts–Wells (BRW) stereotactic frame. The surgical retractor is held and manipulated using a Programmable Universal Manipulation Arm (PUMA) 200 robot (Westinghouse Electric, Pittsburgh, PA) and the position and orientation of the surgical retractor are shown in the 3D display. Both preoperative planning and simulation are important features of this system. The movement of the brain after removal of the tumor and cerebrospinal fluid is substantial, therefore the tumor removal is based on visually defined margins (26). Carney et al. confirmed that intraoperative image guidance is available in otolaryngology (27). The ISG viewing wand (ISG Technologies, Missasauga, ON, Canada) is an intraoperative guidance system with a proprioceptive robotic-like jointed arm. It provides surgeons with almost instantaneously reconstructed computer-generated CT or MRI images in 2D or 3D which can correlate any points within the operative field to its corresponding locus on the reformatted scan images. In this report, 14 patients with skull-base, cerebello-pontine angle or temporal bone lesions also underwent wand-guided resections. Zamorano et al. reported the application of interactive image-guided resections for cerebral cavernous malformation (28). In their report, 15 patients with cavernous malformations underwent an interactive image-guided resection of their lesions. Diagnoses were made using MRI and digital subtraction angiography (DSA). In addition, an infrared system was used intraoperatively to confirm the location and the extent of the resection in real time. Levesque and Parker confirmed the usefulness of Mehrkoordinaten Manipulator (MKM)-guided resection for diffuse brainstem neoplasms (29). Two patients with extensive brainstem tumors underwent a frameless stereotactic craniotomy using an MKM robotic microscope (Carl Zeiss, Oberkochen, Germany) and intraoperative neurophysiological monitoring. Their result shows that image-guided surgery with an MKM microscope allows surgical outlines to be injected in the microscope viewer, thereby facilitating a resection of extensive brainstem tumors that were previously considered inoperable.
Hongo et al. developed NeuRobot, a telecontrolled micromanipulator system for minimally invasive microneurosurgery, at Shinshu University (30). Using this system, surgical simulations were performed with a human cadaveric head. The system consists of four main parts: (i) a micromanipulator (slave manipulator), (ii) a manipulator-supporting device, (iii) an operation-input device (master manipulator) and (iv) a three-dimensional display monitor. Three 1 mm forceps and a three-dimensional endoscope, which could be remotely controlled with three degrees of freedom (rotation, neck swinging and forward/backward motion), were installed in the slave manipulator. All surgical procedures were accurately performed using this system. Furthermore, the same group showed the usefulness of a potassium titanyl phosphate (KTP) laser with micromanipulators in neurosurgery based on an animal study (31). This system was shown to be capable of performing various surgical procedures including cutting, coagulation and bleeding control compared with conventional systems.
Cardiology
The da Vinci was specifically designed to perform closed-chest coronary artery bypass grafting (32) (Table 1). As a result, cardiac surgeons have accumulated substantial experimental experience using the da Vinci prototype (33–35). In 1999, Carpentier et al. reported the first successful use of da Vinci for closed-chest coronary bypass grafting (36). Kappert et al. used da Vinci to harvest both the left and right internal mammary arteries for coronary artery bypass grafting in 27 patients (37). Mohr et al. performed coronary artery bypass surgery using da Vinci for 148 patients (38). In brief, they used da Vinci to harvest 81 left internal mammary arteries (LIMA) and then used it to sew 15 LIMA to left anterior descending (LAD) coronary artery bypass grafts through a median sternotomy incision. Following these patients, they constructed 27 LIMA-to-LAD bypass grafts on an arrested heart with a closed chest. More recently, they succeeded in using the da Vinci to anastomose the LIMA to the LAD on a beating heart with a closed chest. Autschbach et al. established a mitral valve repair for 13 patients using the same system (39).
Regarding ZEUS, in 1999 Reichenspurner et al. reported its first successful clinical use for coronary artery bypass graft for two patients (40). They harvested LIMA using endoscopic techniques and then sutured LIMA to LAD through three thoracic trocars. The heart was arrested using an endovascular cardiopulmonary bypass system. Later that year, Boehm used ZEUS to successfully perform closed-chest, off-pump coronary artery bypass grafting (LIMA to LAD) in three patients (41). By 2000, the same group had performed coronary artery bypass grafting on beating hearts in 10 patients (42). The total operating time ranged from 4 to 8 h (median, 5.5 h) and ZEUS-assisted anastomoses required 14–50 min (median, 25). ZEUS is also used for a pericardiectomy (43) or mitral valve surgery (44).
However, due to the unique characteristics of heart disease, there have so far been no reports on robotic surgery in the treatment of tumors or cancer.
The Respiratory System
Okada et al. performed a thoracoscopic major lung resection for primary lung cancer by a single surgeon with AESOP and an instrument retraction system (UNITRAC; Aesculap, Tuttlingen, Germany) (45) (Table 2). For a 72-year-old woman with lung cancer, a thoracoscopic middle lobectomy of the right lung with dissection of the mediastinal lymph nodes was successfully performed without human assistance and no complications were observed. Melfi et al. carried out thoracoscopic surgery using the da Vinci system in 12 cases: five lobectomies, three tumor enucleations, three excisions and one bulla stitching completed with fibrin glue for spontaneous pneumothorax (46).
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Mediastinum
Yoshino et al. successfully performed a thoracoscopic thymomectomy using da Vinci in a 74-year-old male patient who demonstrated thymoma (47) (Table 2). Ruurda et al. reported a thoracoscopic resection of a schwannoma using da Vinci in a 46-year-old female who presented with a left paravertebral mass in the thorax (48).
Breast
In 2000, Kaiser et al. suggested a strong possibility regarding the application of a robotic system for a biopsy and therapy of breast lesions in a high-field whole-body magnetic resonance tomography unit called the ROBITOM (49). ROBITOM [(robotic system for biopsy and interventional therapy of mammary lesions); Institute for Medical Engineering and Biophysics (IMB), Karlsruhe, Germany] consists of a trocar, coaxial sleeve, biopsy needle, laser applicator and a control and drive unit. In this study, in vitro experiments on a pig liver including eight targets (vitamin E capsules, 4 mm in diameter) were performed as a model of breast cancer and all eight capsules were hit precisely by this robotic biopsy system. The procedure was performed directly in the isocenter of a 1.5 T whole-body scanner. According to these results, such a robotic system may allow the coordinates of the lesion in the breast to be approached in a high magnetic field. Veronesi et al. showed the usefulness of intraoperative radiotherapy (IORT) in limited-stage breast cancers in 103 patients (50). Because local recurrences after breast conserving surgery occur mostly in the quadrant harboring the primary carcinoma, the main objective of postoperative radiotherapy should be sterilization of residual cancer cells in the operative area, while irradiation of the whole breast may be avoided. They developed a new technique of performing IORT on a breast quadrant after removing the primary carcinoma. A mobile linear accelerator (linac) with a robot arm is utilized delivering electron beams capable of producing an amount of energy ranging from 3 to 9 MeV. Seventeen patients received a dose of IORT ranging from 10 to 15 Gy as an anticipated boost to external radiotherapy, while 86 patients received a dose of 17–19–21 Gy intraoperatively as their whole treatment. This IORT treatment allowed the whole treatment course to be shortened.
Recently, MR imaging-guided focused ultrasound US (MR-FUS) ablation has rapidly developed as a non-invasive treatment for breast cancer (51–53). Gianfelice et al. showed the effectiveness of non-invasive MR-FUS ablation in 12 patients with breast carcinomas (51). In brief, before undergoing a tumor resection, patients were treated with MR-FUS ablation consisting of multiple sonications of targeted points that were monitored with temperature-sensitive MR imaging (SignaTM; GE Medical Systems, Milwaukee, WI, USA). The effectiveness of the treatment was determined by a histopathological analysis of the resected mass which was performed to determine the volumes of necrosed and residual tumors. Complications resulting from the procedure were assessed by means of questionnaires, medical examinations and an MR image analysis. US ablation (ExAblateTM 2000; In-Sightec-TxSonics, Haifa, Israel) was well tolerated by the patients and, except for minor skin burns in two patients, no complications occurred. A histopathological analysis of resected tumor sections allowed the quantification of the amount of necrosed and residual tumor and the visualization of the surrounding hemorrhage. In three patients treated with one of the US systems, a mean of 46.7% of the tumor was within the targeted zone and a mean of 43.3% of the cancer tissue was necrosed. In nine patients treated with the other US system, a mean of 95.6% of the tumor was within the targeted zone and a mean of 88.3% of the cancer tissue was necrosed. Residual tumors were identified predominantly at the periphery of the tumor mass, thus indicating the need to increase the total targeted area (51). Huber et al. also revealed the usefulness of MR-FUS ablation in a 56-year-old female who presented with breast cancer (invasive ductal carcinoma) (52). Hynynen et al. also showed the usefulness of MR-FUS ablation for fibroadenoma (53). Eleven fibroadenomas in nine patients under local anesthesia were treated with MR-FUS. Eight of the 11 lesions treated demonstrated a complete or partial lack of contrast material uptake on post-therapy T1-weighted images. Three lesions showed no marked decrease in the contrast material uptake. This lack of effective treatment was most likely due to a lower acoustic power and/or patient movement that caused misregistration. No adverse effects were detected, except for one case of transient edema in the pectoralis muscle 2 days after therapy (53). These papers suggested that (i) invasive ductal carcinoma, (ii) adenocarcinoma, (iii) invasive lobular carcinoma and (iv) fibroadenoma (51–53), were all indications for robotic surgery.
Abdomen
Himpens et al. reported the first successful clinical implementation of telerobotics in March 1997, when they performed a laparoscopic cholecyctectomy using a prototype of the da Vinci (54). The same group also reported a successful use of this system for telerobotic laparoscopic gastric bypass (55), Nissen fundoplication (56,57) and Fallopian tube reanastomosis (58). Other studies showed many kinds of robotic surgery in the abdomen (59–72). Ballantyne and co-workers performed a sigmoid colectomy for diverticulum and right hemicolectomy for cecal diverticulum using da Vinci (59,60) and the operative time for a sigmoid colectomy was 340 min whereas for a right hemicolectomy it was 228 min. The same group also performed the first two cases of ventral hernia repair with mesh (61). Hashizume and co-workers reported the first completely intraabdominal laparoscopic distal gastrectomy for early gastric cancer using da Vinci (6,9). The same group also performed the first gastric devascularization and splenectomy for portal hypertension (6). This report indicates that telepresence technology facilitates these procedures (6,9). Melvin et al. reported a robotic assisted Heller myotomy (67). The same group also performed a pancreatic resection with da Vinci (73). A 46-year old woman presented with back pain and a complex cystic mass in the tail of the pancreas. The da Vinci was used to remove the lesion en bloc with the tail of the pancreas and spleen. Marescaux et al. reported a large clinical trial with ZEUS and 25 selected patients underwent ZEUS-assisted laparoscopic cholecystectomies (74).
Regarding the robotic abdominal surgery for cancer (6,8,54–72), an extraction of esophageal tumor, a distal gastrectomy for gastric cancer, an ileocecal resection for cecal cancer, a left hemicolectomy for descending colon cancer, a sigmoidectomy for sigmoid colon cancer, a thymectomy for thymoma and an extraction for retromediastinal tumor have all been performed successfully. As a result, almost all types of tumors or cancers may therefore be indicated for robotic surgery (Table 3).
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Urology
Abbou et al. reported on a radical prostatectomy using da Vinci (75). The patient was a 63-year-old man presenting with a T1c tumor discovered on one positive sextant biopsy with a 3 + 3 Gleason score and 7 ng/ml. preoperative serum prostate specific antigen. The da Vinci provided an ergonomic surgical environment and a remarkable dexterity enhancement. The operating time was 420 min and the hospital stay lasted 4 days. The bladder catheter was removed 3 days postoperatively and 1 week later the patient was fully continent. A pathological examination showed a pT3a tumor with negative margins (75). Young et al. reported an adrenalectomy for adrenal incidentaloma using da Vinci (76). In this report, an incidental left adrenal mass was found in a patient during an evaluation for mediastinal widening. The patient had no symptoms attributable to adrenal excess. Preoperative biochemical screening was negative for a functioning medullary or cortical adrenal tumor. A surgical resection was successfully completed with the assistance of the da Vinci robotic system. Pathology demonstrated a rare adrenal oncocytoma (76). Recently, in kidney transplantation, a donor nephrectomy has also been performed using the da Vinci (77,78).
Guillonneau et al. reported ZEUS-assisted laparoscopic pelvic lymph node dissection in humans (79). Robotic-assisted laparoscopic pelvic lymph node dissection was performed in 10 consecutive patients with mainly T3 M0 prostatic carcinoma (robotic group). All operations were performed according to the established protocol with no specific intraoperative or postoperative complications. No conversion was required and no technical incidents were observed.
The indications of robotic surgery for cancer/tumor are renal cancer and prostate cancer (Table 4).
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Gynecology
Mettler et al. tried the use of AESOP in 50 patients undergoing routine gynecological endoscopic surgical procedures and AESOP allowed two doctors to perform complex laparoscopic surgery faster than without the robotic arm (80) (Table 5). Diaz-Arrastia et al. reported robotic hysterectomy and salpingo-oophorectomy for 11 patients (81). Molpus et al. reported the first clinical case of robotically assisted endoscopic ovarian transposition using da Vinci (82). Ovarian transposition is the anatomical relocation of the ovaries from the pelvis to the abdomen. Transposition is beneficial in women who are scheduled to undergo pelvic radiation, because it allows the maintenance of ovarian function and preservation of assisted reproductive capacity. In such cases, it is possible to perform ovarian transposition using the da Vinci system (82).
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Regarding robotic surgery, Margossian and co-workers explored the applications of ZEUS in gynecology, using experimental models (83,84). They demonstrated that uterine horn anastomoses in six pigs sutured using ZEUS were all patent 4 weeks after surgery (83). This study highlighted the potential role of robotics for microsurgery. The same group also used ZEUS to perform five hysterectomies in pigs (84), where the mean surgical operating time was 200 min. Regarding the AESOP system, a laparoscopic robot-assisted ovariectomy was performed for ovarian serous cyst (85). Falcone et al. used ZEUS to perform tubal reanastomosis for 10 patients with previous tubal ligations who underwent a laparoscopic tubal ligation (86). The procedure was completed successfully in all 10 patients, none of whom required conversion to an open procedure. A postoperative hysterosalpingogram demonstrated patency in 17 of the 19 (89%) tubes anastomosed and there have been five pregnancies so far (86).
In gynecology also, the MR-FUS has been used to perform operations for uterine leiomyomas (87) and fibroid tumors (88). According to Tempany et al., the eligibility criteria for enrollment were as follows: adult women (age >18 years), premenopausal status with a uterine size of <20 weeks and no dominant leiomyoma >10 cm in diameter (87). MR-FUS was performed successfully in nine women (age range, 39–51 years; mean, 43.4 years) with symptomatic leiomyomas and a hysterectomy was done 3–30 days after MR-FUS as evaluation of its effect.
Pediatric Surgery
The use of robotic surgery has also become widespread in pediatric surgery (89–93) (Table 6). Gutt et al. performed Thal and Nissen fundoplication for GERD, a cholecyctectomy for cholecystolithiasis and bilateral salpingo-oophorectomy for gonadoblastoma using da Vinci for 11 children with a mean age of 12 years (range, 7–16 years) (89). The mean operating time for fundoplication was 146 min, whereas for a cholecystectomy it was 128 min and for a salpingo-oophorectomy it was 95 min and no complications were observed (89). Bentas et al. performed an adrenalectomy for benign adrenal tumors using da Vinci (90). The same group reported pyeloplasty for ureteropelvic junction obstruction (UPJO) using da Vinci (91). In experienced hands, a laparoscopic pyeloplasty is an effective alternative treatment for symptomatic UPJO. Although laparoscopic surgery can clearly benefit patients, laparoscopic pyeloplasty using conventional instrumentation is complex. Eleven pyeloplasties for UPJO were performed via a laparoscopic transperitoneal approach exclusively with the da Vinci. The mean procedure time was 197 min (range, 110–310 min). All operations were completed laparoscopically with no intraoperative complications and negligible blood loss. All patients recovered rapidly after surgery with excellent functional results at the 1 year follow-up. Their initial experience suggests that robot-assisted Anderson–Hynes pyeloplasty is a safe and effective alternative to conventional laparoscopic surgery (91).
Le Bret et al. reported the possibility of robotic surgery for pediatric heart disease (92). Fifty-six children weighing from 2.3 to 57 kg (mean, 12 kg) underwent a surgical closure of a patent ductus arteriosus. They were divided into two groups, one consisting of 28 patients (group 1) who underwent videothoracoscopic techniques and the other of 28 patients (group 2) who underwent a ZEUS-assisted approach. The operating time was significantly longer in the robotically assisted group. One conversion in videothoracoscopy was necessary, but no thoracotomy was required. Three persistent shunts were detected at postoperative echocardiography and were treated by applying a new clip with videothoracoscopy (one in group 1 and two in group 2). No permanent laryngeal nerve injury and no hemorrhage were noted. The mean hospital stay was 3 days in both groups.
Dermatology
In 1988, Rotteleur et al. reported a robotized scanning laser handpiece for the treatment of port wine stains and other angiodysplasias (94). This system is made of a handpiece with a scanning mechanism and a control box with a microprocessor. The system is independent of the laser (no electrical connection) and has its own power meter. The deposit of energy was optimized for effective heat diffusion in the skin. A total of 123 patients were treated with the robotized handpiece and no hypertrophic scars were reported. McDaniel reviewed laser treatment for benign cutaneous vascular disorder in children (95) and showed that automated robotic laser scanning devices allow faster, less painful and more cost-effective treatment.
Handels et al. showed an approach to computer-supported recognition of melanoma based on high-resolution skin surface profiles (96,97). In brief, profiles are generated by sampling an area measuring 4 x 4 mm2 at a resolution of 125 sample points per mm with a laser profilometer at a vertical resolution of 0.1 µm. This new image analysis and pattern recognition method make it easier and more accurate to treat skin tumors (96,97).
Capsule Endoscopy
Since Iddan et al. developed a new wireless capsule endoscopy named device M2ATM (Given Imaging, Yoqneam, Israel) in 2000 (98), this new endoscopy system has been shown to have an excellent diagnostic ability for small bowel disease, bleeding and chronic abdominal pain (99–107).
Small bowel imaging is important in the evaluation of obscure gastrointestinal bleeding (108), inflammatory disease of the small bowel (109) and tumors. The main methods of small bowel imaging have been either enteroscopy or small bowel barium studies for evaluating the luminal pathology. Angiography is a diagnostic option in the context of suspected small intestinal bleeding. Push enteroscopy allows an examination of only 80–120 cm of the small bowel beyond the ligament of Treitz, while intraoperative enteroscopy requires general anesthesia and a laparotomy. Small bowel series and enteroclysis have limited sensitivity and, in particular, could not detect flat lesions such as angiodysplasia (110). Therefore, wireless capsule endoscopy has been applied for many kinds of small bowel diseases (99–107).
Regarding the system of capsule endoscopy, in brief this system comprises the following components: a 26 x 11 mm M2A capsule which contains a miniscule color video-camera equipped with a localization feature, a data recorder which is portable, battery-operated external receiving/recording unit that receives data transmitted by the capsule and subsequently allows data downloading and a Rapid Workstation, a modified personal computer which has been designed for storage, the processing and presentation of captured images and the generation of reports (99–107).
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TOPABSTRACTINTRODUCTIONNAVIGATION SYSTEMSSURGICAL ROBOTSROBOTIC SURGERY FOR TUMORS...PROBLEMSTHE FUTURECONCLUSIONSREFERENCES |
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There are several basic problems that remain to be resolved in order for robotic surgery to spread more widely: (i) the price of surgical robots, (ii) training systems for surgeons, (iii) medical insurance cover, (iv) downsizing and (v) navigation systems. Regarding the price of robotic systems and medical insurance cover, the success of laparoscopic surgery over the past 10 years would endorse further use of robotic surgery (111,112). Regarding the training systems for surgeons, an excellent report on the significance of training has been published (113). Furthermore, our group at the Center for Integration of Advanced Medicine, Life Science and Innovative Technology (CAMIT) of Kyushu University (http://www.camit.org) started a training course called ‘Hands-on Training for Robotic Surgery at Kyushu University’ in July 2003. There are two training courses for robotic surgery. One is a one-day inanimate laboratory course and the other is a two-day course with animate laboratory. Both courses are open not only for medical doctors, but also for wider ranges of researchers in engineering in both academia and industry.
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THE FUTURE |
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TOPABSTRACTINTRODUCTIONNAVIGATION SYSTEMSSURGICAL ROBOTSROBOTIC SURGERY FOR TUMORS...PROBLEMSTHE FUTURECONCLUSIONSREFERENCES |
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Regarding clinical applications, we envisage that almost all surgery can and will be performed by robotic surgery in the future. For that to happen, the following systems should be developed further: (i) an image-guided surgical assistant system, (ii) smaller sized forceps for robots, (iii) capsule endoscopic surgery and (iv) a surgical robotic system. In education and training, training centers for robotic surgery, such as our institute CAMIT, should be established around the world.
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CONCLUSIONS |
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TOPABSTRACTINTRODUCTIONNAVIGATION SYSTEMSSURGICAL ROBOTSROBOTIC SURGERY FOR TUMORS...PROBLEMSTHE FUTURECONCLUSIONSREFERENCES |
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We believe that in the very near future, thanks to the rapid and continuing development of robotic technology, almost all kinds of endoscopic surgery and thoracoscopic/laparoscopic surgery will become performed by robotic surgery, not only for benign disease but also for malignant illnesses.
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FOOTNOTES |
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+ For reprints and all correspondence: Makoto Hashizume, Department of Disaster and Emergency Medicine, Graduate School of Medical Sciences, Kyushu University, 3–1–1 Maidashi, Higashi-ku, Fukuoka 812-8582, Japan. E-mail: mhashi{at}dem.med.kyushu-u.ac.jp
Abbreviations: 3D, three dimensional; CG, computer graphics; CAD, computer-aided design; CAM, computer-aided manufacturing; AESOP, automated endoscope system for optimal positioning; IORT, intraoperative radiotherapy; CT, computed tomography; MR, magnetic resonance; MRI, magnetic resonance imaging; FUS, focused ultrasound surgery; CAMIT, Center for Integration of Advanced Medicine, Life Science and Innovative Technology; MIS, minimally invasive surgery; PUMA, programmable universal manipulation arm; LIMA, left internal mammary arteries; LAD, left anterior descending
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REFERENCES |
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