机器人系列roboticsin

Robotics in Surgery Marc S. Milsten, M.D., F.A.C.S. Urologic Specialists of Oklahoma November 17, 2007 Definition of a Robot lMachine that resembles a human and does mechanical, routine tasks on command lAny mechanical device that operates automatically with human-like skill l“A robot is not a machine.it is an information system with arms” Robots: Better Than Humans? Robots: Better Than Humans? Types of Robots lPassive lRetractor system lPosition the tool and then hold lActive lRobot would actively move the tool upon the surgeons command Surgical Robots in 2007 lAESOP (Automated Endoscopic System for Optimal Positioning) - Voice activated mechanical arm - Steadier than human, never tires ldaVinci - FDA approval in 2002 - Laparoscopic instrumentation controlled by the surgeon positioned remotely at a console Development of daVinci lDefense Advanced Research Projects Agency (DARPA) for military research of remote battlefield surgery lCholecystectomy performed remotely via telesurgery from 300 miles away lIntuitive Surgical created in 1999 after acquiring patent rights from military lFirst robotic prostatectomy performed in 2001 “Operation Lindberg”: Remote Transatlantic Telesurgery Remote Surgery Advantages of Laparoscopic Surgery lShorter hospital stay lLess pain lLess risk of infection lLess blood loss and transfusions lLess scarring lFaster recovery lQuicker return to normal activities Challenges of Laparoscopic Prostatectomy lProstate located in fixed confines of pelvis lLaparoscopic instruments limited in articulated movements lApproximation of bladder-urethral anastomosis difficult to suture lFrench experience: 300 cases reported, learning curve 100 lOklahoma experience: 1 case, 19 hours, patient died Advantages of daVinci Robot lMagnified (12x), stereoscopic 3-D vision lRobotic wrist with 6 degrees of freedom lMovements are scaled, filtered, translated daVinci Robotic System Disadvantages of daVinci Robot lExpensive - $1.4 million cost for machine - $120,000 annual maintenance contract - Disposable instruments $2000/case - Hospital reimbursement same DRG lSteep surgical learning curve lIncreased staff training/competance lIncreased OR set-up/turnover time Robotic Disbelievers l“No long term data” - Margin positive rates equivalent - No difference in risk for incontinence and erectile dysfunction l“Loss of tactile feedback” - Improved vision - Haptic feedback: visual resistance lENABLER: same operation, new tool daVinci Robotic Prostatectomy OpenRobotic OR time3 hrs2-4 hrs Hospital stay3 days24 hrs Foley catheter14 days7 days Blood loss600 ml130 prostatectomies performed to date lAverage operative time 2-3 hours l95% patients discharged in 24 hours lNo conversions to open surgery lComplications: 2 post-op bleed, 1 port site hernia, 1 anastomotic stricture daVinci Clinical Applications lUrology: radical prostatectomy, dismembered pyeloplasty, radical cystectomy, cyst decortication lCardiac: mitral and aortic valve replacement, aorto-iliac bypass, off-pump synchronized bypass lGYN: hysterectomy, prolapse repair, tubal reversals, fistula repair, myomectomy lGeneral: gastric bypass, Nissen daVinci Clinical Limitations lNo advantage over standard laparscopic approach for cholecystectomy, spleenectomy, colectomy lIncreased operative time observed lPrecise dissection not necessary lOpen space: limitations with broad sweeping motions daVinci vs. Laparoscopy lLaparoscopic surgical fellow at Stanford lFirst 50 Roux-en-Y procedures randomized laparoscopic or robotic with DaVinci lBoth surgery with hand-sewn anastomosis lOR time: 149 min (lap) vs 131 min (robot) lNo difference for complications, LOS, EBL lConclusion: Robot is an ENABLER Off-pump CABG l30 patients, 2.6 grafts/patient lMajority: IMA to LAD l15/30 discharged 24 hours lComplications: - 2 return to OR for bleeding - 1 converted to open - 2 readmits: pleural effusion, wound infection lNo mortality Advanced Endoscopy Natural Orifice Surgery Courtesy of N Reddy, Hyperbad India 20005 Courtesy of N Reddy, Hyperbad India 20005 Peroral Transgastric Endoscopic Surgery Natural Orifice Transluminal Endoscopic Surgery (NOTES) Trans-gastric Appendectomy Climbing the Learning Curve lStandard surgery: “see one, do one, teach one” lRobotic surgery: “see one, do one, kill one” lRequires entirely new skill set beyond traditional surgical and laparoscopic training lTraining opportunities limited lAnimal labs helpful lCases require outside proctor to determine competency lCredentialing challenges? Surgical Simulation Surgical Simulation Red Dragon/Blue Dragon Hand Motion Assessment Robotic Rounding Robotic Scrub Nurse “Penelope” Robotic Scrub Nurse Operating Room of the Future Moral Dilemma lTechnology is neutral - it is neither good or evil lIt is up to us to breathe the moral and ethical life into these technologies lAnd then apply them with empathy and compassion for each and every patient Conclusions lThe rate of discovery of new technology is outpacing the ability of business, society, and he