Page 29 - World Association of Laparoscopic Surgeons - Journal

B Srinivas

LIMITATIONS OF ROBOTIC-ASSISTED SURGERY • The presence of a replaced right hepatic artery and
the position of the 1st jejunal vein (J1) branch, as it
Patient safety in the event of robot malfunction and crash
enters the right side of the superior mesenteric vein,
down is a concern and the operating room staff should be
should be assessed in order to avoid any inadvertent
aware of it. Robotic technology is a complex issue and needs
injury
a lot of practice and technical expertise. Robotic surgery
• Short stature and obesity create excess intra-
needs longer operating room time compared with
abdominal fat which makes robotic dissection
conventional surgeries. Several pieces of equipment, each
difficult.
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being extremely bulky, require large operating room space.
2. Laparoscopy, port setting and robot docking: A
The staff must be trained and prepared to quickly detach
laparoscopic investigation of the abdominal cavity is
and remove the robot from the patient in the event of an
essential prior to any major pancreas tumor resection
emergency. Current robotic systems lack tactile feedback
(NCCN guidelines). The laparoscopy not only allows
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from the instruments.
surgical staging, but also allows identification of acute
Surgeons have to rely on visual clues to modulate the
or chronic pancreatitis, an unfavorable body habitus or
amount of tension and pressure applied to tissues to avoid 10
other unforeseen obstacles to a robotic procedure.
organ damage. The newly launched da Vinci HD SI system
Robotic trocar placement: The camera port is positioned
costs $1.75 million. Initial increased operating room setup
slightly to the patient’s right side and inferior to the
time and surgical time adds to the cost burden. However,
umbilicus. The camera port is approximately 18 cm from
robot- assisted surgery has shown to reduce hospital stay
the operative focus, and the robotic axis is slightly to
by about half and thereby cutting hospital cost by about
the patient’s right side of midline. The right robotic arm
33%. 13
is placed in the upper left-hand corner of the abdomen.
One major obstacle to the telerobotic surgery is the
The robotic left hand is in the patient’s left lower
‘latent time’, which is the time taken to send an electrical
quadrant, with the robotic 3rd arm below the patient’s
signal from a hand motion to actual visualization of the
right costal margin (after pneumoperitonealization).
hand motion on a remote screen. Humans can compensate Assistant operating ports are positioned in the right and
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for delays of less than 200 msec (Table 1). Longer delays
left abdominal quadrants. The robotic ports should be
compromise surgical accuracy and safety. Incompatibility
8 to 10 cm apart, if possible, while the assistant ports
with imaging equipment is an area that needs attention. 10
should be at least 5 cm from additional port sites.
3. Mobilization of duodenum (kocherization) and exposure
THE STEPS IN A ROBOTIC WHIPPLE
of the superior mesenteric/portal vein
PROCEDURE (FIGS 3 TO 5)
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4. Exploration of the porta hepatis
1. Preoperative considerations: Patient and disease 5. Mobilization of the ligament of Treitz
factors: 6. Transecting the pancreas and dissecting the uncinate
• Preoperative evaluation of acute or chronic process
pancreatitis which if present makes robotic dissection 7. Reconstruction: Pancreaticojejunostomy, hepatico-
difficult jejunostomy and gastrojejunostomy.
Table 1: Advantages and disadvantages of conventional laparoscopic surgery vs robot-assisted surgery
Conventional laparoscopic surgery Robot-assisted surgery
Advantages Well-developed technology 3D visualization
Affordable and ubiquitous Improved dexterity
Proven efficacy Seven degrees of freedom
Elimination of fulcrum effect
Elimination of physiologic tremors
Ability to scale motions
Microanastomoses possible
Telesurgery
Ergonomic position
Disadvantages Loss of touch sensation Absence of touch sensation
Loss of 3D visualization Very expensive
Compromised dexterity High start-up cost
Limited degrees of motion May require extra staff to operate
The fulcrum effect New technology
Amplification of physiologic tremors Unproven benefit

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