Page 34 - Laparoscopic Surgery Online Journal

Mohammed Khairy Ali et al

surgeon’s fingers to the tip of the surgical instruments. DISADVANTAGES OF THE ROBOTIC SURGERY
Despite all of these technologic advancements that make
The main disadvantages of robotic surgery applications
the surgeon nearly autonomous, an assistant is still required
are the cost, the large size of the robot and console, limited
for all robot-assisted cases. Their responsibility is mainly
availability within some health systems, lack of tactile
instrument exchanges, suction and irrigation, suture
feedback, the need to train surgeons, and operating room
introduction and retrieval and additional retraction. 12
availability on the use of this technology. The costs
associated with robotic surgery include the cost of the unit
ADVANTAGES OF THE ROBOTIC SURGERY
that can range from 1.4 to 1.6 million dollars and the cost
Robotic surgery offers several advantages over laparoscopy:
of instrumentation that has limited its uses. Health systems
A 3D vision, wristed instrumentation, and comfortable
need to perform an investment analysis which gives fixed
positioning for the surgeon while performing surgical
costs associated with the purchase, high robotic surgical
procedures. The only currently available surgical robot
volume is required to improve this calculation. Additional
employs two magnifying cameras that when used provide
costs that need to be considered include the time and cost
3D vision to the surgeon with an available high-definition
of training surgeons and operating room and increased
vision system. This enhanced visualization gives the
operative time associated with operating room setup as
gynecologist the ability to identify tissue planes, blood
well as the assembly and disassembly of the robotic system
vessels and nerves while performing the surgical procedure,
during the early phase of the training. There is evidence
also decreased blood loss has been reported in robotic
that with experience in robotic surgery, the operative time
surgery. The limited degrees of freedom associated with a 16
can become shorter than with laparoscopy. The bedside
standard laparoscopic instrument compared with the surgeon
assistant may experience difficulty in manipulating
hand decrease the dexterity of the surgeon and his ability to
laparoscopic instruments through an assistant port because
perform delicate procedures like difficult dissections, lymph the robotic arms are moving over the patient abdomen at
node removal. Wristed instrumentation allows the the same time. Although robotic instrument exchange can
gynecologic surgeon to obtain the exact instrument angle become more efficient compared with laparoscopy but it
available at laparotomy. This also eliminates the fulcrum still requires attachment of the robotic instruments to the
effect that is present with conventional laparoscopy, where instrument arms before insertion. Another current
surgeons need to move their hand in the opposite direction limitation of robotic surgery is the lack of tactile feedback,
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to the certain location of the distal instrument tip. With so if there are particular structures that the surgeon desires
robotic surgery the movements are natural and surgeons to palpate, they can do by laparoscopy before using the
move their hands in the direction they want the instruments robot or ask the bedside assistant to palpate and confirm
to move. Three degrees are provided by the robotic arms the location. Moving the robot to the operating table and
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attached to the abdominal wall trocars (insertion, pitch, yaw), attaching the robotic arms to the trocars is often a major
and 4º result from the ‘wristed’ instruments (pitch, yaw, disadvantage requiring significant time. With practice and
roll and grip). The terms pitch, roll and yaw are the three training, this can be performed quickly but in more time
characteristics that describe the rotations in three dimensions that require with laparoscopy. Because the operating table
around the robotic instrument. Pitch is the rotation around and the robot do not communicate and are not
the lateral or transverse axis. The yaw is rotation about the synchronized, once the robotic unit is united, the patient
vertical axis, and the roll is rotation around the longitudinal bed cannot be moved in any direction, otherwise, the trocar
axis. The improved dexterity and control allow for finer, depth can become incorrectly positioned and abdominal
more delicate, tremor-free manipulation, dissection, removal wall as well as visceral trauma could occur. Increased
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or reconstruction of tissue. Fatigue and physical discomfort operative time associated with some robotic surgeries
can become limitations during any surgical procedure. which may have associated side effects, including
During laparoscopy, surgeons are often suffering from anesthetic complications. 18 Finally the size of both the
difficult technique to complete the surgical procedure robotic unit and console become a major consideration.
because they need to reach over the patient’s abdomen to Depending on current operating room size and availability,
manipulate the hand controls on the laparoscopic relocation to a larger operating room may be necessary.
instruments. With robotic surgery, the surgeon sits Many of these disadvantages could be improved with
comfortably at the surgical console and manipulates the hand further development. Table 1 shows the advantages and
controls and foot pedals. This may serve to reduce fatigue disadvantages of conventional laparoscopic surgery vs
and discomfort during complex surgical procedures. 15 robot surgery.
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