6 Telesurgical Robots
Abstract
Telesurgical robots are machines that allow for the completion of complex and delicate surgical tasks under direct control of an operative surgeon. These robots are indefatigable, capable of performing precise maneuvers in confined spaces, and controlled through a remote workstation that can be positioned anywhere, from beside the patient to another operating room around the world. Several telerobotic systems have been developed, with proven applications in cardiac, general surgical, urologic, gynecologic, and laparoscopic procedures. More recently, applications in spinal surgery have begun to emerge with procedures such as anterior lumbar interbody fusion and paraspinal tumor excision demonstrating successful integration of telesurgical technologies. This chapter outlines the evolution of telesurgical robot technology and provides an overview of current and future surgical capabilities of the most commonly used system, da Vinci, particularly as it relates to applications in spinal surgery.
6.1 Introduction
Telerobotic surgery has its origins in battlefield medicine. After successful demonstration of telesurgical open bowel anastomosis with the system created by Phil Green and colleagues with the Stanford Research Institute (SRI), the United States Army utilized Department of Defense grants and collaboration with the Defense Advanced Research Projects Agency (DARPA) to prototype a mechanism to allow surgeons to operate on combat casualties at a site remote from the battlefield. 1 Their vision was to deploy robotic arms to casualties via armored vehicles to the site of the battlefield injury while the surgeon remained at the forward surgical hospital controlling the robot remotely. This was performed for the first time in 1994 when a porcine intestinal anastomosis was performed via wireless microwave connection.
6.2 ZEUS Robotic System
Commercially available modern telesurgical robots began with the implementation of the ZEUS system (Computer Motion, Santa Barbara, CA) in 1998. ZEUS introduced the concept of master–slave telepresence surgery with the surgeon at a console remote from the patient. 2 The ZEUS robot consists of a Storz 3D imaging system (Karl Storz Endoscopy, Santa Barbara, CA) and three arms, two of which are surgical and the third an automated imaging arm. The ZEUS robot achieved success in closed chest beating heart cardiac surgery and successfully performed a telerobotic cholecystectomy on a patient in Strasbourg, France, with the surgeon and console in New York. 3 , 4 , 5 , 6 , 7 The ZEUS robot was produced until 2003 when its parent company merged with Intuitive Surgical. It was subsequently phased out in favor of the now commonplace da Vinci Telesurgical System (Fig. 6‑1).
6.3 da Vinci Robotic System
Following the successful trials of the Department of Defense and DARPA prototypes, the surgeon and entrepreneur Frederick H. Moll created Intuitive Surgical, a company founded on the goal of solving the limitations of conventional endoscopic surgery by advancing the concept of telerobotic surgery. 1 , 8
The da Vinci robotic system (Intuitive Surgical, Sunnyvale, CA) is currently the only Food and Drug Administration (FDA)-approved robot for laparoscopic surgery and the most well-known with over 1,400 units deployed in the United States as of 2011 and the number of telesurgical procedures increasing 400% over the preceding 4 years. 9 In 1997, the first telesurgical robotic cholecystectomy was performed and in the following year, the first cardiac revascularization procedure was performed with early versions of the da Vinci. While the initial development of the system focused on the potential role for cardiac revascularization, results in this field lagged behind those in general surgery and the device was first FDA-approved in 2000 for general laparoscopic abdominal surgeries. 10 , 11 , 12 , 13 In the same year, the first robotic prostatectomy was performed utilizing the da Vinci which heralded the beginning of the robot’s widespread use in urologic and gynecologic surgeries (Fig. 6‑2). 14 , 15
6.3.1 Design
The da Vinci is a master–slave style robotic system with separate surgical and control consoles. The control console is composed of a computer and 3D imaging system and is responsible for remotely controlling the robotic arms. The surgical tower is deactivated by an infrared sensor when the surgeon’s eyes exit the binoculars, thus acting as a safety mechanism to prevent inadvertent movements. The robot is able to imitate the human wrist with seven degrees of freedom and two planes of axial rotation, providing maximal dexterity within the tight confines of the surgical space. Limited haptic feedback is available to the surgeon through resistance of movement, when tensioning suture, for example; however, the majority of tactile information is derived from visual clues. 7 The da Vinci employs binocular endoscopic vision to immerse the surgeon in a 3D experience, enhancing depth perception and special awareness. 16 This is created by two independent scopes within the 12-mm telescope whose images are transmitted to separate but synchronized screens inside the surgeon’s console. 17
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