Decoding Robotic Surgery in Cancer

  •   Mon, Jan 20 2025
  •   By Dr Elroy Saldanha

January 20, 2025

Introduction:

Over the past few decades, advancement in science and technology played a huge role in medical field. From the times where ether was first used as a inhalation agent (October 16, 1846 at Massachusetts General Hospital in Boston, United States) for anaesthesia purposes by Dr William Morton to this date, as the anaesthesia machines improved for the better anaesthesia and pain relief during the surgery, so did the surgical instruments. From having a crude knives to current surgical blades, from the open surgery to a key hole surgery (i.e. laparoscopic and robotic surgery); advancements in science and technology helped the patients recover better from their recent surgical experience. One such innovation is the Soft Tissue Robotic Systems. It has revolutionised present day surgical techniques, with a possibility of performing radical surgeries with minimal scars and thereby reducing post-operative pain leading to early recovery of the patients.

The first use of a robot-supported surgical intervention was reported in 1985, when the robot arm PUMA 560 placed a needle for a cerebral (brain) biopsy using CT guidance. Since then, robotic surgery has seen a significant growth due to a rising demand for automation in the healthcare as a whole and greater concentration on minimally invasive surgery (MIS) for faster recovery. Today, robotic surgery is transforming complex surgical procedures by combining precision with good patient outcomes. Apart from many internationally available robotic systems, one such popular Robotic system is da Vinci Robotic Systems and the other is the Indian Robotic System SSI Mantra under Make in India initiative. One of the reasons for the invention of the robotic system was to perform tele-surgery where the operating surgeon would utilise the surgeons console and operate on a patient attached with patient cart of the robotic system in two different locations which would helpful to cater the war victims for the critical lifesaving procedures at the combat zone. Rightly so, ZEUS was the first commercially available surgical robot to complete a transatlantic surgery (“The Lindbergh” surgery) with Dr Marescaux performing robotic minimally invasive cholecystectomy between New York City and his patient, a 68-year-old woman in Strasbourg, France on September 7, 2001. But currently due to the consumer protection acts and raising patient litigations tele-surgery has taken a back seat and that busts a popular myth of the robotic surgeon being unavailable in operation theatres when robotic surgeries are going on. In fact, Robotic Surgeon and his team would be on the patient bedside when the complex robotic procedure being performed (Figure 1).

Robotic system:

Robotic systems usually contains 3 parts which is inter-connected to each other viz. surgeons console, patient cart and visual cart (Figure 2).

  1. Surgeons Console: Here, a trained robotic surgeon utilises the robotic platform to perform complex surgeries and the myth of robot independently being able to perform a surgery is not true! This console is powered by 3D visualisation and 12 x magnification of the camera which facilitates precision based fine surgery and thereby reducing the blood loss and post-surgery blood requirement. It is equipped with infra-red rays which locks to robotic arms if in case the surgeon diverts attention away from the console. Likewise, in the event of a power failure or technical issue, the robot remains stationary, preventing accidental damage. Additionally, surgeons and their teams are fully prepared to take over manually if necessary, adding an extra layer of security. So, the likelihood of a robotic system malfunctioning during surgery is extremely low, with less than a 2% chance of minor issues and only a 0.1% chance of significant malfunctions. (Figure 3)
  2. Patient cart: Based on the robotic systems, the 4 arms is either mounted on a single column (da Vinci) or it can be separate 4 arms with column (SSI Mantra). This arms has got multiple joints which avoids the fulcrum of the robotic arm force on the patient abdomen/chest wall thereby the post-operative pain is quite minimal. Each arm passes through the patient’s abdomen/chest wall through 8mm ports which the surgical instruments are mounted and it is targeted on the organ of interest for the surgery. Robotic instruments have wrist-like motion, similar to a human arm with 7 degrees of freedom (Figure 3), whereas Laparoscopic Instruments are straight and less flexible. Robotic surgery enables more precise movements in difficult-to-reach areas, offering additional benefits such as tremor filtration and motion scaling. These features allow the surgeon to perform intricate procedures with greater control and dexterity than traditional laparoscopy. Additionally, the enhanced vision provided by the 3D, magnified view in robotic surgery helps the surgeon to identify and preserve vital structures, nerves, and blood vessels during the procedure. This precision can lead to less postoperative pain, improved functional outcomes, and faster recovery for the patient than a laparoscopy procedure. All these features makes Robotic Surgery far superior to the Laparoscopic Surgery.
  3. Vision cart: It contains monitors for the bedside assistant surgeons, infra-red fluorescence called the Fire-Fly Technology for guiding surgeons to identify targeted lymph nodes, vascularity of the anatomic structure (Figure 3).

Apart from these, Robotic systems are being powered with AI for the stapling devices during the surgeries for example Sureform Smartfire Staplers. 

Applications:

Soft Tissue Robotic Systems can be used for many procedures, including gastrointestinal surgery, oncological surgery and heart surgery. Their flexibility and precision along with 3D, magnified view and advanced instruments make them suitable for simple and complex surgeries, further broadening their application in modern medicine leading to safer and more effective cancer treatments. In many cases, robotic surgery yields better results than open surgery or laparoscopy, especially when dealing with complex or hard-to-reach areas like human pelvic and thoracic surgeries. Studies have shown that robotic surgery can lead to more precise tumor removal, reduced recurrence rates, and improved long-term outcomes for cancer patients. For orthopaedic surgery, the robotic systems are bit different while compared to the Soft Tissue Robotic Systems

Benefits:

Apart from smaller incisions and scars, Robotic Surgery also offers other benefits such as Reduced Blood Loss, Faster Recovery, Safer Operations, Shorter Operative Time, and an early discharge from the hospital. These advantages make robotic surgery an attractive option for many patients and medical professionals alike. In addition, the precision of robotic surgery can help preserve surrounding healthy tissue and minimize complications, leading to better overall patient outcomes.

Busting Popular Myths:

  1. Robots do the surgery on their own:

Fact: Robotic surgery is actually robot-assisted surgery, where it 100% surgeon controlled as the system functions as a master-slave relationship. The surgeon controls the robotic arms and instruments from a console within the operating room, making exact movements. The robot cannot make decisions or perform surgery without the surgeon’s guidance, ensuring the human element remains central to every procedure. The robot serves as an extension of the surgeon’s skills, similar to how a driver controls a car or a pilot flies an airplane. The surgeon’s experience and expertise are crucial in ensuring a successful robotic surgery outcome.

  1. Robotic Surgery is experimental:

Fact: Robotic surgery is a well-established practice in leading hospital worldwide.Surgeons are extensively trained before operating robotic systems, ensuring the technology is used safely and effectively. Additionally, numerous studies have demonstrated that robotic surgery provides similar or better outcomes than traditional surgery like open/laparoscopic, especially regarding patient recovery time, reduced pain, complete removal of the disease and fewer complications.

  1. Robotic surgery is too expensive:

Fact: Robotic surgery may have been costly when it was first introduced due to high equipment costs. The development of more affordable robotic systems have significantly reduced the price. But, it offers numerous benefits over traditional methods. These advantages include improved surgical precision, faster recovery, shorter operative time, and reduced blood loss. It’s like, if a person needs to travel to Mumbai from Mangalore. This can be done by transport bus (open surgery), train (laparoscopic) or flight (robotic surgery). The cost for individual mode of travel varies and it’s based on one’s comfort, time schedule and affordability. The extra cost can be offset by the reduced hospital stay and quicker return to work while compared to open and laparoscopic surgeries. Thus, robotic surgery ultimately improves the patient’s overall experience, mental and emotional stress. Additionally, as robotic surgery becomes more widespread, the cost is expected to decrease, making it more accessible to patients. Currently, many of the insurance companies partially or completely covers the cost of robotic surgery.

  1. The surgeon operates from a separate room during robotic surgery.

Fact: The surgeon, assistant, anaesthetist, and nursing staff are all present in the operating room during robotic surgery. The distance between the surgeon and the robotic system is minimal, ensuring clear communication and coordination among the entire surgical team. This proximity allows for real-time adjustments and quick decision-making during the procedure, contributing to a safer and more efficient surgical experience (Figure 1).

  1. Any surgeon can easily perform robotic surgery.

Fact: Acquiring the skills necessary for robotic surgery requires extensive training and practice. Access to a robotic system does not guarantee superior surgical outcomes. Surgeons must be accredited and undergo rigorous training to master the art of robotic surgery. A surgeon’s experience and expertise play a significant role in the success of robotic surgery procedures. It takes a year in the fellowship programs to train a surgeon. Moreover, continued education and staying updated on the latest advancements in robotic surgery are essential for surgeons to maintain their proficiency in this specialized field (Figure 4: My training in the console in New York Langone Hospital for Thoracic Oncology and Figure 5: Latest da Vinci 5 Robotic system hands on training). 

 

 

To Conclude:

Robotic surgery is a cutting-edge technology that offers numerous advantages over traditional surgical methods like faster recovery and improved outcomes, thanks to the reduced trauma to the body, small incisions and precision surgery. However, misconceptions and myths surrounding this innovative approach often lead to confusion and doubt. By debunking these myths and providing accurate information, we hope to empower patients and medical professionals to make informed decisions about the use of robotic surgery in their treatment plans. As technology continues to advance, robotic surgery will likely play an increasingly significant role in modern medicine, providing safer and more effective treatment options for patients worldwide. If you need any further information for the same, feel free to contact me.

 

 

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By Dr Elroy Saldanha
Dr Elroy Saldanha is the Consultant Surgical Oncologist, Father Muller Medical College Hospital, Mangaluru. He is the first trained Robotic Surgical Oncologist in the Coastal Karnataka under Vattikuti Foundation, Southfield, Michigan, USA in Manipal & Aster Hospitals, Bengaluru. He has received training in colorectal unit, Cleveland Clinic, Ohio and Thoracic Oncology training in New York Langone Hospital and a Certified Tobacco Cessation Specialist, Gujarat University. He is an avid researcher, with several presentations, research papers, review articles and textbook chapters published in National and International print to his credit.
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