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  • Robots assist in common surgery

Mar 2009
Caren B. Les,

LONDON – It appears that robotic systems have the potential to replace humans when it comes to assisting surgeons with a commonly performed minimally invasive procedure to remove a patient’s gallbladder.

Known as laparoscopic cholecystectomy, the surgery involves the use of a laparoscope and other surgical instruments that are inserted into the abdomen of a patient via two or three minor incisions. The laparoscope is a miniaturized video camera system designed to fit inside the body and to transmit magnified images of internal organs onto a monitor. The laparoscopic technique typically replaces open surgery, which is associated with greater risks for complications, more patient discomfort and longer hospital stays.

The surgeon typically has relied on a human assistant to move the camera as needed during the procedure. Recently, however, scientists have reviewed clinical trials to compare the effectiveness and safety of robotic versus human assistance during laparoscopic cholecystectomy, and the results suggest that the robots may be just as suitable for the task.

Robots could be helpful in situations such as emergency surgery, when a human assistant may not be available, or in countries where work hours for human assistants are limited. They also are advantageous in that they can hold the camera steady over long periods of time.

Researchers led by Kurinchi S. Gurusamy, from the department of surgery at Royal Free Hospital in London, reviewed data taken from five randomized trials that included a total of 453 patients who underwent the procedure, 159 belonging to the robot assistant group and 165 to the human assistant group. They found that there was no statistically significant difference between the two groups in terms of morbidity, the need to switch to open surgery, total operating time or length of stay in the hospital. Instrument setup time was found to be much shorter in the human assistant group, however.
Gurusamy said that robot assistants have no significant advantage over human assistants in the accuracy or error rate. He added that this is not to say that robotic assistance will prove better or worse than human assistance in the accuracy and error rate if future trials are conducted with adequate numbers of patients recruited.

Which type of system?

When asked about the types of robotic systems available for the task, Gurusamy said that each has its advantages and disadvantages. The EndoAssist, for example, uses the surgeon’s head movements for camera control, while the Aesop system uses the surgeon’s voice commands. Both approaches allow only the camera to be controlled, Gurusamy said.

The EndoAssist robotic surgical assistant made by Prosurgics Ltd. of Loudwater, UK, is used in a minimally invasive procedure to remove a patient’s gallbladder. The freestanding laparoscopic camera manipulator is controlled by infrared signals from a headset worn by the surgeon. The company recently released a next-generation version, the FreeHand, which is smaller and less expensive. Other types of robotic surgical assistants also are available. Photo courtesy of Prosurgics.

The Passist system, another alternative, is a manually controlled mechanical arm that can lock the laparoscope and an additional grasper in the desired position, allowing for adjustments using one hand. The Da Vinci and Zeus systems enable telerobotic surgery, during which the surgeon uses a console to control the robotic arms.

All of these systems need trained operators, Gurusamy said. Once surgeons are trained in two or more methods of using the robotic assistants, comparisons can be made to determine the superiority of one type over another.

Cost-effectiveness considered

Gurusamy said that the future of robotic assistance in laparoscopic cholecystectomy is likely to be determined by cost-effectiveness rather than by improved patient outcomes. He added that more randomized control trials using cost-effectiveness measures as one of the outcomes should be performed to enable accurate assessment of the role of robotic assistance in laparoscopic gallbladder removal.

In the foreseeable future, robot systems that require no human instruction most likely will be developed to assist with certain surgical procedures, Gurusamy said.

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