News & Articles - Robot-Enhanced Operations in Gynaecology

ROBOT-ENHANCED OPERATIONS IN GYNAECOLOGY
THE QUANTUM LEAP FORWARD

DR SURESH NAIR
MBBS, MMED (O&G) FRCOG (UK)
Consultant Obstetrician & Gynecologist
Parkway Fertility Centre
Mount Elizabeth Hospital, Singapore

Over the past two decades, great strides have been made in how surgeons do operations. One significant advance has been “key-hole” surgery or minimal access surgery (MAS). The traditional way of doing an operation requires the surgeon to make large incisions on the abdomen to remove or repair diseased or damaged organs.

With key-hole or MAS, a telescope (laparoscope) is passed through a 1cm incision into the umbilicus to which a small digital camera is attached and images of the internal organs displayed on a monitor (fig 1).

Further instruments necessary to do the operation are introduced through other small incisions (5mm to 10mm) for the surgeon to use long narrow instruments to operate.

However, this type of surgery sometimes requires the surgeon to adopt uncomfortable positions which can impact on the performance of the more complicated operations.

Now there is a surgeon-controlled robotic “humanoid hand” that is miniaturized such that it can be passed into the abdomen with just an 8mm incision! (fig 2) The da Vinci robot is an immersive (i.e. as if the surgeon is looking through a glass clad abdomen) telerobotic surgical system designed to accurately follow movements of the surgeon’s hands i.e. a slave robot not an auto-robot like in the automobile industry. Furthermore, it is intuitive as the surgeon moves his hand from right to left to move the robotic instruments in the same direction. Conventional laparoscopic surgery is counter intuitive. The surgeon has to readapt against our natural orientation such that to move the tip of the instrument from right to left, the brain has to signal the hands to do the contrary – hence making this type of surgery harder to master.

The key factors of the da Vinci robot that makes it far superior to conventional laparoscopy is as follows:

Improved, crystal clear, 3D stereoscopic vision over the operating field without the need for polarizing glasses. (fig 3)
Laparoscopic instruments with intra-abdominal articulation in 7 d.o.f.; surpassing movements of the human wrist; 2 articulations within 2cm of the instrument tip provide 360° rotation & flexion. (fig 4)
Articulated ends that can be directed to the appropriate plane for precise tissue dissection instead of forcing the tissues to align in the direction of rigid instruments; Ambidexterity
During suturing, the needle can easily be positioned in any direction, allowing accurate placement of sutures.
Outcome: gentle & precise tissue dissection; effortless suturing & intracorporeal knot tying & improved suturing accuracy
Studies comparing laparoscopic & robotic suturing, articulation & motion scaling of robotic instruments enhanced dexterity by 50% & 3D vision improved it by further 10-15%. This resulted in 93% reduction in skill- based errors.
Comparative studies between robot-enhanced and conventional laparoscopic suturing consistently showed faster, more precise suturing with a shorter learning curve in robotic surgery.

Operations such as removal of growths (fibroids) in the uterus that requires very precise and fine stitching to close to uterine defect made in the uterus is very securely done using the da Vinci Surgical Robot from Intuitive Surgical. (fig 5 – 8) The repair of the myomectomy defect is extremely critical in the integrity of the subsequent scar. Inadequate suture repair predisposes to uterine rupture in pregnancy – a catastrophic complication that endangers mother and child.

For the first time in minimal access surgery, the surgeon has a three dimensional view of the organs through the stereoscopic viewer (fig 9) as the great disadvantages of conventional two-dimensional laparoscopy is the loss of depth of field of vision. The surgeon is able to perform very precise and accurate surgery yet seated comfortably at the surgeon console. This reduces surgeon fatigue. (fig 12)

The robot can filter out natural hand tremors and scale down movements (fig 14, 15) for microsurgery – much like the gears of a racing bicycle that allows the biker to cycle more revolutions but to move uphill without excessive effort. In this way, delicate suturing using fine suture down to 8סּ or 9סּ requiring a very high degree of surgical dexterity can be easily accomplished by the majority of surgeons. Procedures such as tubal reanastomosis where the tubal lumen is only one millimeter in diameter can be expeditiously completed.

Robotic surgery allows operations to be completed with less blood loss, very little pain because of small incisions and allows patient to be up and about after surgery, recover faster and be able to go home faster.

Operations in gynaecology that can be done via the da Vinci robot are:

Removal of fibroids in the uterus (myomectomy) with a secure repair strong enough to hold a pregnancy.
Removal of diseased uteri – hysterectomy.
Removal of cysts in the ovary – cystectomy.
Joining fallopian tubes after tubal ligation (sterilization) – microsurgery using stitches as fine as human hair can be done very fast and precisely using the robot because of the tremor filtration and stereoscopic vision.
After child-bearing the uterus can descent through the vagina as the vagina and its muscles are loosened (prolapse). Robotic stitching is very quick yet secure and the pelvic muscles can be repaired and tightened. Urinary stress incontinence can also be corrected in this way.
Colposuspension in urinary stress incontinence
Treatment of endometriosis that causes period and pelvic pain - difficult dissection in awkward areas and around the bowels, ureters, rectovaginal septum can be accomplished because of the 7 d.o.f. of movement of the robotic instruments.
Removal of cancers of the uterus and cervix – radical hysterectomy and lymphadnectomy
Fertility operations to repair damaged fallopian tubes so that the patient can conceive without having to go through IVF. Microsurgical neosalpingostomy and salpingoophorolysis that require fine and precise movements.
Correcting in-born (congenital) abnormalities in the uterus or scarring that causes miscarriages – the robot can be used to repair and reconstruct uterine defects to minimize the risk of miscarriages.

Robot-enhanced surgery is therefore a natural progression from current laparoscopic surgery to precise surgeon intuitive surgery of the future.

Fig 1 : Laparoscopic surgery using the voice activated laparoscopic system with the surgeon moving the instruments directly and working off a 2 dimensional video monitor

Fig 2 : Surgical instruments attached to robotic arms through adaptor via 8mm da Vinci – specific port

Fig 3 : Insite vision system in central robotic arm - provides crystal clear 3-dimensional stereoscopic vision over the operative field

Fig 4 : Robotic instruments capable of 7 degrees of freedom (d.o.f.) of movement

Fig 5 : Enulceation of the fibroids

Fig 6 : Secure closure of the deeper layers of the myomectomy defect

Fig 7 : Meticulous fine precise suture closure of the edges of the myomectomy defect at the surface of the uterus

Fig 8 : The complete suture line providing a secure and strong repair with procurement of haemostasis

Fig 9 : Stereoscopic viewer; infrared beam deactivates robotic arms whenever surgeon moves head out of console.

Fig 10 : Console controls

Fig 11 : Dual 5mm endolenses through a 12mm port with a high resolution digital camera attached to it to provide crystal clear 3 dimensional binocular vision through the above stereoscopic viewer which provides real life perception of depth very essential for safe and accurate surgery

Fig 12 : Surgeon console

Fig 13 : During robot-enhanced surgery, the robot is docked in place upon the patient. There is a right and left robotic “hand” that is controlled from the console by the surgeon’s right and left hand for precise and accurate surgery.

Fig 14 : Surgeon’s hands inserted into free-moving “masters” or finger controls, convert into electric signals, translated to computer commands directing robotic instruments to perform same movement

Fig 15 : Motion-scaling & tremor filtration (esp for microsurgery); down-scaling of surgeon’s movements at selected ratios (5:1, 3:1, 1:1) ; down-scaling improved surgeon’s accuracy & precision, while filtrating of hand tremors appears to have a lesser role for accuracy.