This reappraisal paper discusses the applications of robotic systems in general and pectoral surgeries. The benefits and limitations related to the usage of automatons in comparing with the traditional attacks are besides discussed. Particular mention is made sing the operation length and hospitalization clip utilizing the automaton technique in comparing with the traditional methods. Cholecystectomies, intervention of gastroesophageal reflux disease and esophageal achalasia, bariatric surgeries, colon operations and thymectomies are merely some of the general and pectoral surgical processs that can be performed with the support of automaton engineerings.
Harmonizing to the reappraisal the effectivity of robotics in the above processs has been proved in many clinical tests depicting successful results. The presently available systems are chiefly based in ocular 3-dimensional feedback. The limitations of the robotic surgeries are based to the fact that sawboness, normally use their custodies during the operations. The deficiency of tactile sense is considered to be the one of the most of import disadvantages of modern systems. All decisions refering surgical robotics should ever take into history that it is a comparatively recent engineering which has non been utilised adequately which has non yet go a common portion of the mundane surgical pattern.
The term telemedicine refers to the combined usage of telecommunications and information sciences for the proviso of health care services and education/counseling from distance. Telemedicine uses e-messages to reassign medical informations from one site to another. These messages can be biosignals, laboratory trial consequences, 2D and 3D images, electronic wellness record information etc. The above mentioned informations may be transmitted alongside with audio and picture. The informations transportation can be synchronal or asynchronous and may be transmitted through a telephone line, the cyberspace, an organisation ‘s intranet or a satellite connexion. The first telemedicine applications appeared in the 70s and were used for reding and proviso of instructions to ships, in the instance of an exigency event. The visual aspect of the first computing machine systems and the development of communicating engineerings during the 80s and 90s contributed to the rapid development of telemedicine applications ( 1 ) , such as telediagnosis, tele-consultation, teleactinology, telecardiology and telecare.
Telesurgery is a field of telemedicine with rapid development in the recent old ages. Actually the doctors ‘ involvement to visually reexamine the internal variety meats has existed since the ancient clip. The first described endoscopy was by Hippocrates who made mention to a rectal speculum ( 2 ) .A The term telesurgery refers to the sawbones supported by automaton systems being at his service during the surgical operation. Techniques back uping laparoscopic operations and the proviso of support, audience and instruction, are major applications of great impact. The development and use of automaton systems, such as the Zeus and da Vinci system within the clinical environment makes it possible to execute surgical operations from distance. Apart from the demand in modern telecommunication services, there is the demand for the appropriate package and hardware in order to accomplish the simulation of the existent surgery site. For this ground, practical world engineerings are being used.
Image 1: Use of district attorney Vinci automaton system during an operation
The first distance assisted surgical operations have been performed in 1999 in Singapore, in connexion with John Hopkins Hospital ( Baltimore, USA ) . Other similar operations followed up during the following old ages. This has been achieved with the usage of a teleconsultation platform with existent clip sound and video support and the distance control of a AESOP 1000TS automaton arm. The application has been supported by three ISDN lines ( baud rate 384 Kbps/sec ) , while the control of the automaton arm was enabled through a 2nd parallel line. The surgical operations included successful resections and the distance between the J. Hopkins and the client infirmaries varied between 7200 and 17600 kilometer. The slowdown clip was within the acceptable bounds in the above processs but excessively long for a strictly distance operated process ( 3 ) . In the twelvemonth 2001 the tele coaction system Socrates, has been used together with the automaton surgical system Zeus for the first strictly telesurgical operation. An amended version of the above system, viz. Zeus TS, has been used in an over Atlantic cholecystectomy by Dr. Jacques Marescaux on a 68 old female patient. The automaton system and the patient were located in Strasburg, France while the sawbones and the control panel were 7000 Km off, in New York, USA.
In the instance of really long distances, the signal needs a few msecs to be transmitted and this is a really important issue to be taken into history. Even the usage of geosynchronous orbiters appears to hold a hold clip of 1.5 sec. Marescaux and Gagner estimated that a safe surgical process from distance should hold a hold clip no longer than 300 msecs. ( 4 ) An optical I‘I¤I? connexion has been used due to the high velocity ( 10Mb/s ) and the service quality, in a cholecystectomy has been performed with success. This surgical operation is known as Lindbergh operation ( 5 ) . Finally, in the twelvemonth 2003 the first tele automaton supported operation has been performed in Canada between two infirmaries 400 kilometers off from each other.
Harmonizing to the Robotics Institute of the Carnegie Mellon University, USA, a automaton is a reprogrammable accountant of multiple maps that has been specifically designed to travel objects, tools and devices through programmable motions in order to carry through assorted activities. The rule of automaton engineering is the digital control ( method of reprogramming tools-machines ) and telechirics ( the usage of mechanical weaponries to execute physical manus activities ) ( 6 ) , ( 7 ) . The mechanical portion of a automaton includes their weaponries. Based on the activity that the automaton system has been designed for, the automaton may include one or more weaponries. Each arm is made of the undermentioned parts:
Base: fixed onto the automaton and attached with connections and articulations which are connected with the action tool.
Connections: solid, metal parts which keep together the arm of the automaton system.
Joints: mechanisms that allow the comparative motion between two connections.
Motors: used to travel the articulations and detectors for the control of the location and velocity of articulations.
Action tool: it is a specifically designed tool located onto the arm of the automaton system.
Each traveling joint adds one grade of freedom ( DF ) to the automaton. In order to depict the place of a solid object in infinite we need to specify six variables, three for its location and three for its orientation. Therefore each automaton system should hold at least 6 DFs. The human arm is estimated to hold about 7 DFs ( 8 ) .
The surgical automaton
Harmonizing to the theory, if a automaton is built upon suited package, it has the ability to execute a surgical operation. The surgical automaton is a computing machine controlled device that has been programmed to execute precise motions of surgical tools, therefore back uping the sawbones to execute complex operations. It is of import to emphasize that the surgical automatons can non execute operations entirely be themselves and map in dependance with the sawbones, functioning as their “ mechanical extensions ” . There is a master-slave relationship between automaton systems and the sawbones. Each master-slave system consists of two parts, viz. the console-master of the sawbones and his automaton arms-slaves. The console is the interconnectedness between the sawbones with the automaton system. The computing machine is placed between the patient and sawbones, supplying valuable information. Through digital analysis, the robotic system provides precise three dimensional imaging to the sawbones. The bids of the sawbones with the usage of controls are interpreted into precise digital signals to the surgical arms-slaves ( 9 ) .
Roboticss in Medical Practice
Minimally invasive surgery ( MIS ) has been introduced 25 old ages ago, taking to back up medical operations with minimum injury and shortest possible recovery clip. This method was based on microcameras attached onto devices called endoscopes or laparoscopes which go through little holes of 1 centimeters throughout the patient ‘s organic structure with the assistance of a proctor. The success was so great that a new specialisation started to be, viz. the laparoscopic surgery. It has been the first clip that the control of the surgical field has been taken over by the individual who controls the system. In clinical surgical pattern, automatons are used in all about fortes, including neurosurgery, cardiovascular surgery, orthopedicss, general surgery, urogenital medicine and the gynaecology. Most robotic operations emanate from cardiovascular and urological surgery.
Scope and Methods
This reappraisal paper discusses the applications of robotic systems in general and pectoral surgeries. The benefits and limitations related to the usage of automatons in comparing with the traditional attacks are besides discussed. Particular mention is made sing the operation length and hospitalization clip utilizing the automaton technique in comparing with the traditional methods.
An drawn-out literature research has been made utilizing Medline. The research identified those reappraisal documents and clinical tests which describe operations that have been performed utilizing automaton engineerings and refer to the field of general and pectoral surgery. The presentation of the clinical tests pinpoint to the benefits and limitations of the automaton techniques, while a comparing is made with traditional methods, every bit far as specific indexs are concerned. These indexs include the clip continuance of the surgery, the post-operation hospitalization length and the rate of successful operations while in some instances mention is made sing the in-surgery complications.
Applications in general and thoracic surgery
The application of robotics in general and pectoral surgery and more specifically in the gastrointerine system is comparatively new. Up to now, robotic systems have been used in laparoscopic cholecystectomies, in operations for the intervention of gastroesophageal reflux disease and esophageal achalasia, in surgeries for the pathological fleshiness, in colon and rectum operations, every bit good as in the instance of lien and pancreas surgeries. The field of thoracic surgery eventually describes robotic operations in the lungs and the Thymus.
The first automaton supported cholecystectomy was performed by Himpens in March 1997 with the assistance of the MONA system, precursor of robotic district attorney Vinci system, and was completed in 82 proceedingss. Cadiere performed 48 cholecystectomies, utilizing the district attorney Vinci system. The average operation clip length was 70 proceedingss. In 4 instances the disease has been the ague cholecystitis, while in one instance blood transfusion was performed during the operation. The average figure of hospitalization yearss was 2. The usage of the robotic system provided improved motor accomplishment, superior ergonomy and increased mobility of the tools, while the clip needed for the operation and the hospitalization were found to be within the acceptable bounds. Marescaux and his squad performed 25 cholecystectomies in 2001 utilizing the system Zeus, including 20 diagnostic instances of cholelithiasis, 4 ague instances and one instance with polyps. The clinical results of the intercessions were satisfactory, while in one merely instance there was the demand to execute an unfastened surgical operation. In September 2001, following experiments in hogs, Marescaux and his squad performed the first transatlantic robotics cholecystectomy enduring 54 proceedingss, known as operation Lindbergh ( 10 ) .
Image 1: Robotic Cholecystectomy
Treatment of gastroesophageal reflux disease
The surgical techniques that are used for the intervention of the gastroesophageal reflux disease are two, viz. tholoplasty Nissen, or tholoplasty 360O. The sawboness make 4-5 little 5 millimeter holes throughout the tegument without muscular cut ( 11 ) .
The first automaton supported Nissen operations were performed by Cadiere in 1999. Cadiere performed 10 such robotic operations utilizing the MONA system and 11 operations utilizing the authoritative laparoscopic method. The average continuance of the automaton supported operations was well longer than that of the conventional laparoscopic methods ( 76 and 52 proceedingss severally ) , while the average hospitalization yearss was similar in the two instances. Despite the fact that the robotics method was proved to be a executable and safe technique, it did non demo important advantages against the laparoscopic technique. Due to the narrow stomachic infinite and the curving stomachic morphology during the operation at that place have non been performed adequate robotics operations for the intervention of gastroesophageal reflux disease, either with tholoplasty Nissen or with any other technique. Based on the consequences of these clinical tests the robotic tholoplasty Nissen gives similar patient results with the conventional technique, but it is a more precise and slower operational process. The mortality rates in all instances were void ( 12 ) .
Treatment of the Esophageal Achalasia
Esophageal Achalasia is a upset which is related with the mobility of the gorge. The cause is normally unknown. The gorge is unable to execute its peristaltic motion and the lower portion of the gorge clinch does non open sufficiently when nutrient goes through, being in changeless paroxysm. The disease is frequent in the ages between 30-60 old ages in one out of 100.000 patients and its symptoms are dysphagia, A diverticula and weight loss. The laparoscopic surgical intervention of the esophageal achalasia is called myotomy Heller and in certain instances is performed alongside with laparoscopic tholoplasty Dor ( 180 [ O ] ) or Toupet ( 270 [ O ] ) . Small surgical scratchs ( 5 millimeter ) allow the endoscope and the surgical tools to come in the venters. Then, a little scratch in the muscular tissue of the gorge is made and, if needed, the operation is followed up by a fictile surgery of the gorge ( 11 ) .
Harmonizing to a study published in 2004 in Chicago by Jacobsen et Al. ( 13 ) on the public presentation of 35 robotic Heller myotomies, there have been perfectly no instances of esophageal perforation, an accomplishment related with fact the elaborate 3-dimensional position of the muscular system of gorge and the broad scope of motions of the specialised EndoWrist tools of the district attorney Vinci system. The average continuance of the automaton supported myotomies was well smaller when compared with that of the conventional laparoscopic operations ( 10 ) .
While the job of fleshiness has received epidemic dimensions in the western universe, there has been a considerable addition in the figure of patients traveling through bariatric surgical operations, in order to lose weight. Nowadays, bariatric surgery for the intervention of pathological fleshiness constitutes an independent surgical sector with many possibilities and chances. The higher part of these operations is being performed with conventional laparoscopic techniques, while merely late some of them are performed with the support of robotic engineering. These include the technique of silastic stomachic ring ( LAP-Band ) , the stomachic beltway Roux-en-Y ( stomachic beltway ) and oblong gastrectomy ( sleeve gastrectomy ) .
Silastic gastric ring
The stomachic ring surgery is one of the most popular operations for the intervention of pathological fleshiness. In the upper portion of the tummy and near the gorge, a silastic ring is placed, which drastically limits the measure of nutrient that passes through the tummy. The ring is connected with a membranophone that is implanted onto the venters. The method is performed either with the laparoscopic technique or with robotic method ( 14 ) . The importance of the robotic district attorney Vinci system in bariatric surgeries has been proved through a series of operations, specifically in the instance of stomachic ring or stomachic beltway operations. The mortality rates in all instances were void ( 12 ) .
Gastric beltway Roux-en-Y
Of all operations for the intervention of pathological fleshiness, the stomachic beltway Roux-en-Y is the largely applied technique. A little portion of the tummy is straight connected with the bowel, so the nutrient passes through a long manner across the gastrointerine path ( 14 ) .
The laparoscopic operation can besides be performed with the robotic method with similar surgical continuance in comparing with the conventional technique and besides with minimum hazard of morbidity or mortality. The robotic method constitutes an alternate technique for the accomplishment of gastrostomy and the inosculation offering of import advantages to the bariatric sawbones. The 3-dimensional word picture of the surgical field and the extra grades of freedom allow the sawbones to execute better and more precise surgical suturas, which the method well decreases the opportunities of gastrointerine escape. The hospitalization length remains the same, irrespective of the followed technique.
Datas from stomachic beltway Roux-en-Y operations performed within a five-year-period, showed that the robotic method, was even more precise than the conventional surgical technique, demoing of import advantages. The information concerned 605 instances of patients. 356 of them followed the conventional laparoscopic technique while 249 patients were treated with the robotic method ( 15 ) .
Vertical Sleeve gastrectomy
Sleeve gastrectomy is an operation for the intervention of fleshiness that has started to be used late. It is the remotion of a big portion of the tummy without nevertheless upseting well the normal operation of digestion and soaking up of alimentary constituents. With this technique the 85 % of tummy is removed vertically, while the staying portion of the tummy is rejoined. This is an operation besides performed with the support of robotic surgery with the aid of four to five little ( 1 centimeter ) scratchs ( 14 ) .
Robot Supported Colon Operations
Many operations have been performed in the colon and the rectum utilizing robotic systems. Some of these operations include right and left colon extraction, sigmoid colon extraction, orchidopexy, low anterior extraction and entire colon extraction. However, despite the advanced proficient features of the district attorney Vinci system, most studies on robotic colon surgeries do non show any of import advantages of against the traditional laparoscopic technique.
Since Weber and his squad announced the two first colectomies with the aid of the robotic system district attorney Vinci in March 2001, colostomy operations with the support of robotics have been increased. Clinical surveies have shown the feasibleness and the safety of robotic colectomies non merely for the intervention of non-malignant but besides in malignant colon diseases. The comparing of 18 instances of right and 10 left semi-colectomy with the support of robotics with 50 instances of right and 73 instances of left laparoscopic semi-colectomy, suggests that the robotic colon surgeries is a executable and safe method but requires a longer clip for the operation to finish ( 16 ) . Delaney et. Al besides found similar to the old survey consequences ( 17 ) . Similarly, another survey indicated that the clinical consequences of the robotic and laparoscopic colectomies were similar, while the robotic operations required well longer clip in the instance of the right colectomy. The longer clip continuance of the robotic techniques was attributed, to the endosomatic inosculation. However, there is no cogent evidence that the peculiar inosculation is a better method in colectomy operations in comparing with the exterior inosculation ( 18 ) .
Harmonizing to the above mentioned studies, the robotics colectomy is proved to be a executable and safe method, but it is non related with better clinical results despite the fact that the robotic system district attorney Vinci is a technological measure towards compared to the authoritative laparoscopic tools. For this ground, the relation between the technological virtuousnesss of district attorney Vinci and anatomic features during the colectomy should be taken into history. The big surgical field during the operation limits that advantages offered by the 3-dimensional position that supports the robotic system ( eg x10 rapid climb, stableness ) . The sawbones has a good position of the surgical field, even when using the x2 expansion that the authoritative laparoscopic technique offers, while a well-trained helper can manage the laparoscopic camera.
In add-on, the easy and suited draft of the traditional laparoscopic tools compensates for the advantages of the two added grades of freedom of robotic system during the colectomy operation, due to the big size of the surgical field which is non limited by any bone constructions ( eg the basin ) . The robotic surgery is in general, executable and safe method for colectomy operations. Up until now nevertheless, it does non look to be related with better clinical results when compared with the unfastened or conventional laparoscopic method. There are yet much needed technological developments to be utilized, such as the tactile feedback and the designing of particular tools for suited for drawing out the redundant colon. Furthermore, the betterment of in exterior freedom of the robotic arm is besides expected to be a technically improve colon operations, while hits between the weaponries of system normally happens because the extraction of the redundant colon requires an external ( out-of-body ) motion of the robotic arm ( 19 ) .
Myasthenia gravis is rare disease that causes upset of the normal neuromuscular synapsis and is characterized by progressive and rapid loss of muscular force during repeated or uninterrupted attempts. Since 1941, when Blalock and his co-workers reported the results of the first thymectomy on patients with serious myasthenia, this method has acquired an of import function in the intervention of the peculiar disease. A figure of techniques can be used for the remotion of the thyme, viz. the traditional thymectomy through the sternum, thymectomy through the scruff, the thoracoscopic attack with the assistance of a moving image and, more late, the robotic supported thymectomy with the surgical district attorney Vinci system.
Sing the last mentioned method, there already exist certain few surveies that confirm the safety and effectivity of the technique. Rea et. Al ( 20 ) describe 33 instances of patients, 24 adult females and 9 work forces with ( average age=41 old ages ) , who were treated with robotic thoracoscopic thymectomy for heavy myasthenia without thymoma. The operations were performed between April 2002 and October 2004 in Italy. A left-side attack was adopted during the operations, via 3 little scratchs because this provided better oculus contact with the surgical field and decreased the opportunities of by chance wounding the phrenic nerve cell. The average clip continuance of the operations was 120 proceedingss and they were all successful without the visual aspect of any complications. Merely two patients ( 6 % ) presented post surgical complications. The average hospitalization length was 2.6 yearss. The rating of the first 24 patients, after a average station surgical period of 23.8 months, showed that 4 of them ( 16.7 % ) were cured and 18 of them ( 75 % ) were found to demo clinical betterment.
Merely a few instances of surgical operations with the support of robotic systems, in the lien, the pancreas, the gorge and the bowel have been reported, while the added value of the usage of automatons in hepatic operations is under consideration. The first application of robotic surgery in the pancreas concerned the remotion of a neuroendocrinic tumour with the aid of district attorney Vinci system and was performed by Melvin in 2003 ( 21 ) .
In another instance, 8 patients went through a duodeno-pancreatic extraction. During these operations, hepato- and gastro- jejunoileal stomies were internally performed manually ( with the sawbones ‘s manus ) . The deficiency of tactile feedback engineerings restrict, at least for now, the usage of robotics in complex pancreatic operations. Such surgical procedure is besides the operation Whipple, in which the usage of sawbones ‘s manus is perfectly indispensable ( 22 ) . In splinectomy operations, the district attorney Vinci system helps the sawbones find the vas construction and chalk out out the spleen country while the preciseness of the surgical EndoWrist tools facilitates the exposure of spleen vass. In 2003, nevertheless, Talamini et Al. reported 2 ammendments in unfastened surgical methods that they had to do due to the troubles that met in 7 instances of robotics operation, suggesting that spleen extractions should non be performed by robotics surgeries.
In another series of spleen extraction in 2005 that were performed by Bodner ‘s squad in 7 patients, utilizing district attorney Vinci the system, there were observed no complications during the operation and no change in the predefined process was needed. The squad concludes that robotics extraction of the lien with the district attorney Vinci system is technically executable and safe, while it constitutes an option of the conventional laparoscopic method. Nevertheless, the squad underlines that a limitation of this robotic system is the deficiency of compatible devices. For this ground, the surgical control of the sutura of the splenetic gate should be performed with the usage of conventional devices ( 10 ) .
Liver robotic surgery methods are yet under development and for this ground there are non many studies that support the effectivity of such techniques. A series of left partial extractions were performed in the liver of 3 patients in the twelvemonth 2007 in Seoul, and the procedure showed that the peculiar technique is besides executable and safe for patients with little malignant tumours and non-malignant hepatic diseases. The first of these instances concerned a hepatocytic carcinoma ( HCC ) , the 2nd patient was diagnosed with colon malignant neoplastic disease with liver metastasis, while the 3rd instance concerned the being of endohepatic rocks. The above three operations were successful and the patients recovered without any complications. The hospitalization length was smaller than the corresponding conventional methods, while the patients started eating usually ( from oral cavity ) early. Nevertheless, the first patient developed hepatocytic malignant neoplastic disease three months after the operation ( 23 ) .
The surgical automatons constitute an built-in piece of medical scientific disciplines. Commercial systems are already available many old ages now, and their clinical value has already been under scientific rating with the aid of clinical tests. As an illustration, the control possibilities and the multiple grades of freedom offered by the district attorney Vinci system increase the virtuosity and bound the manus shudder of the sawbones, while the improved and elaborate visual image of the surgical field allows the execution of micro anastomosiss. In assorted instances, modern robotic systems decrease the length of hospitalization clip and the above fact is related with positive results for the patients but besides economic addition for infirmaries.
There is a position sing robotic systems as portion of the information systems, holding the ability to back up engineerings that are developed and already in usage within the surgical hall. An illustration of the above is the meeting of images from the assorted scrutinies ( ie topography ) with the image of the surgical field for the most effectual counsel of the sawbones towards the designation of pathology and the public presentation of accurate scratchs. This information can every bit be used for the execution of pre-operational tests in complex operations. The nature of robotic systems besides supports the possibility for consultative services from experts and the counsel of operations from distance, while it provides chances for the preparation and rating of new sawboness via simulation.
Telesurgery is the following measure of surgical robotics and despite assorted limitations it appears to hold great possible. One should, nevertheless recognise that telesurgery is merely one facet of telemedicine, and that all other applications, when combined together contribute to the betterment of medical attention. Since the telecommunications engineering makes rapid advancement and the comparative costs have significantly decreased, it is expected that telemedicine, including telesurgical applications should hold an of import impact in future.
Despite the fact that the effectivity of robotics in surgical systems has been proved, it is of import to acknowledge a figure of issues related with the high cost of purchase and care every bit good as with the massiveness and weight within the surgical room ( eg district attorney Vinci system ) . Extra issues that should be considered is the version within the new robotic world, the preparation of the medical and nursing staff and the credence of the new engineering both by sawboness and the patients. All decisions refering surgical robotics should ever take into history that it is a comparatively recent engineering which has non been utilised adequate and has non yet become common portion of the mundane surgical pattern. No decisions can be made on the long term consequences of the usage of automaton systems and on the ultimate signifier the engineering will be eventually incorporated in most infirmaries ( 24 ) .
Robot systems are expected to maintain improving and their development will assist confront the restrictions described in this paper. Aim of the research workers is to develop robot systems that will let the sawboness to experience and to hold control of the tissues in a “ natural ” manner during the operations. The presently available systems are based chiefly in ocular feedback. Magnified 3-dimensional theoretical accounts guide the sawboness bespeaking them the morbid tissues, so that the sum of force that needs to be applied by the automaton system can be controlled. Surgeons, nevertheless, normally use their custodies during the operations and their actions are based on the information the touch of the tissues offers to them. The deficiency of tactile sense is considered to be the one of the most of import disadvantages of modern systems. Even though there are many detectors and methods of control that offer tactile feedback, there are assorted issues that have to be resolved, viz. the cost, the complexness and their compatibility with the robotic systems and the human tissues ( 25 ) .
The familiarisation of sawboness with the new engineering is another of import facet. Some of them face robotics in surgery with modesty. This reaction is normal and expected, due to the fact that surgical instruction has remained unchanged for more than one century. Even though many immature sawboness seem to be interested in the application of robotic systems, really few establishments offer the needed instruction and preparation. The integrating of surgical robotics in the course of study is non merely expected to cut down the acquisition curve of new sawboness but it is should besides take to of import alterations in the manner immature sawboness improve their surgical accomplishments, with the support of practical environments.