BY DR AJAY PAI, KGMU

1. Dr Ajay Pai
Moderator : Dr Pradeep Joshi
ROBOTICS IN GI SURGERY:
CURRENT STATUS

2. Outline
 History
 Definitions
 Types of robots
 da Vinci surgical system
 Recent developments
 Summary

3. History
 Derived from the Czech word robota, meaning “forced labor.”
 Word robot first used by Capek in play Rossum's Universal Robots in 1921
 First developed by NASA for use in space exploration.
Satava RM. Surg Laparosc Endosc Percutan Tech 2002
Murphy D et al. Postgrad Med J 2006
 Mid-1990s –
Automated Endoscopic System for Optimal Positioning (AESOP) for
voice-controlled optimal camera positioning, and
Laparoscopic Assisted Robotic Systems (LARS) for organ retraction.
 1997 - DaVinci system (Intuitive Surgical)
US FDA approval in 2000
Bought Zeus system
Schurr MO et al. Surg Endosc 2000

4.  1997 – first robotic cholecystectomy
 1998 – first robotically assisted heart bypass by Dr Friedrich Wilhelm Mohr
using Da Vinci
 2007 – first robotic pancreatectomy by Prof Pier Giulianotti at Chicago
 2008 – first minimally invasive liver resection for LDLT
 Surge in no. of cases
 1500 cases in 2000 to 20000 in 2004
 Majority : Urology procedures (prostatectomy)
 Marescaux and colleagues - first robot-assisted laparoscopic cholecystectomy
between New York and Strausbourg, France, 2001
Marescaux J et al. Nature 2001
Marescaux J et al. Ann Surg 2002

5. Definitions
 Robotic surgery –
autonomous, reprogrammable manipulator designed to move and articulate
instruments through programmed motions to achieve specific task.
 Robotically assisted surgery –
mechanical devices under partially programmed control by surgeon's
intervention.
 Telesurgery – ability to perform surgery using computer-assisted
instruments from remote location.
 Telemanipulation – ability to produce electronically precise instrument
movements at distance from remote location.
 Telepresence – virtual projection of images from remote sites. Allows
surgeon to visualize intended robotic movements at distant locations.
 Telementoring – supervision and instruction from distant location

6. 7 degrees of freedom -
1. three arm movements (in out, up down, side
to side),
2. three wrist movements (side to side, up and
down, roll) and
3. grasping or cutting.

7. Types of robots
 Industrial robots –
preprogrammed highly precise, repetitive tasks
tasks invoked on command
used in orthopedic surgery and neurosurgery
 Assist device –
control instrument location under guidance
not autonomous, need input cues
AESOP
 Telemanipulator –
under constant control
da Vinci

8. daVinci Surgical System (dVSS)
 Developed by Intuitive Surgical (Sunny Valley, California) designed to enable and
enhance Minimally invasive surgery.
 First surgical robotics system cleared in 2000 by US FDA
 Initially for laparoscopic surgery, later for thoracoscopic, urologic, gynecologic
surgeries, and some cardiac procedures
 Computer enhances interaction between surgeon and bedside robotic device by
1) Eliminating tremors
2) Scaling all motions to a selected degree.
 Evolution- S version in 2006 to Si (2009) and finally da Vinci Xi cleared in 2014.
 By 2014, 2585 systems installed worldwide ( 1878 USA, 416 Europe and 291 rest of
the world)

9. DESIGN
1. Surgical console,
2. Patient cart, and
3. Optical 3-d vision tower

10. Surgical Console
 Viewing space similar to double-
eyepiece microscope – 3D Vision
 Manipulation with two masters –
levers attached to index fingers and
thumbs of each hand.
Wrist movements replicate movements
of instruments at end of robotic arms.
 Foot pedals for
 Disengaging robotic motions
 Allowing adjustment of endoscopic
camera, and
 Controlling energy of electric
cauterization.
 Allows more precise surgical
procedures and intuitive orientation
makes tasks easier.

11. Optical tower
 Computer equipment
1. Integrate left and right
optical channels for
stereoscopic vision
2. Run software for controlling
kinematics of robotic arms.
 Interfaces translated motion of
surgeon's hands to digital code
that moves mechanical levers,
motors, and cables
 Four arms for real time manipulation
by surgeon
 First two arms represent surgeon's
right and left arms,
 Third arm positions endoscope.
 Optional fourth arm to hold another
instrument or additional tasks
 Bulky and very heavy- wheeled to
vicinity of patient and locked
 Patient must be guarded against
inadvertent contact from motions of
robotic arms.
 After instruments are engaged and
inside patient, patient's body position
cannot be modified unless
instruments are disengaged and
removed
Patient cart

13.  Improved ergonomics
 Stabilisation of instruments with mechanical advantage over traditional
laparoscopy

14. daVinci Clinical Applications
 Although great promise across broad range of
surgical disciplines, no Level 1 data to strongly
support RS.

15. Robotics in GI Surgery
FOREGUT SURGERY
 Some of the largest data sets for Robotic GI surgery, mainly
Nissen fundoplication and Heller Myotomy.
 Robotic assisted Laparoscopic Heller Myotomy ( RALHM)
was reported in 2001 followed by a small case series.
 Universities across the US prospectively collected data of
104 cases of RALHM and found
1. Both lap and robotic safe and low complication rates.
2. However no clear benefit seen in robotic group.

16.  Horgan et al (2016) reported an esophageal perforation
rate of 16% in their LHM group compared with 0% for
the RALHM group.
 Several RCTs compared robotic vs lap Nissen
fundoplication
1. No distinct advantage offered by robot aside from
increased operative time.
2. Owen et al (2013) at University of Nebraska reported
similar outcomes except increased cost.

17.  General GI procedures –
Tomulescu V, Romania
 129 procedures in 1 yr
 Cholecystectomy, fundoplication, gastrectomy, gastro- enterostomies and
bowel anastomosis, splenectomy, adrenalectomy, liver cyst fenestration
 Best indications: 1) procedures that require small operating field,
2) fine precise dissection and
3) safe intracorporeal sutures.
Tomulescu V. Chirurgia. 2009

18. ROBOTIC GASTRECTOMY
 Guilianotti in 2003 first reported robotics in management of
gastric cancer.
 Limited comparison series exist between robotic and lap
gastrectomy.
 Kim et al (2017) compared robotic vs lap vs open looking
specifically at oncologic outcomes
1. LN harvest did not differ significantly.
2. Robotic surgery associated with less blood loss.
3. Shorter hospital stay with robotic surgery.
Morbidity 9-30% and mortaliy 0-9% in literature.

19.  GI luminal malignancies –
Anderson C, CA
 73 procedures in 3 yrs
 Esophagectomy, gastrectomy, proctectomy
 Leak rate : 16, 9 and 11% resp.
 LN harvested : 22, 26 and 13 resp.
 One recurrence at 9m & 30 day mortality zero
 Safe and feasible for variety of radical oncological procedures
Anderson C. Int J Med Robot. 2007

20. BARIATRIC SURGERY
 Only operative procedure studied in any volume is the Roux en
Y Gastric Bypass (RYGB).
 Totally robotic RYGB has beein described in 5 systemic
reviewsas a safe and effective alternative to open and lap
techniques.
 All published reviews report non inferiority and fail to
demonstrate superiority of robotic approach over std.
laparosopy due to lack of high quality data.
 An RCT by Sanchez et al in 2005 showed equivalent outcomes.

21.  Data from case control studies show some benefit in
reducing GJ Leaks, strictures and length of stay, non being
statistically significant.
 However facilitates hand sewn GJ offering several
advantages compared to laparoscopy
1. Added degrees of freedom
2. Ambidextrous suture placement
However paucity of data comparing the two approaches.

22.  Described for both benign and malignant hepatic resections.
 No RCT however exists to compare robotic assistance with conventional lap for
hepatic resections
 Giulianotti PC, University of Illinois, Chicago
 70 resections by single surgeon
 60% malignant; 40% benign
 Median duration for major resection : 313 min
minor resection : 198 min
 Median blood loss : 150 ml
 Mortality nil and morbidity 21%
 Conversion rate : 5.7%
 Safe, with min conversion, blood loss, morbidity
Giulianotti PC. Surgery. 2011
ROBOTIC LIVER SURGERY

23.  A systematic review of literature by Berber et al in 2010
-19 case series reviewed
-236 robotic provedures in 219 patients
-Both benign and malignant tumors included.
-Tumor size up to 6.4 cm.
-Wedge resection was most common procedure f/b Right
hepatectomy, left lateral sectionectomy, left hepatectomy
and
bisegmentectomy.
-Conversion to open in 10 cases (4.6%)
-Morbidity rates 20.3% cited with MC being Intra abdominal
biloma or abscess in 6-7% each.
-No mortality reported.
 Robotic hepatectomy feasible but comparisons to evaluate
oncologic outcomes, cost effectiveness and morbidity cannot be
determined with existing data.

24. ROBOT ASSISTED PANCREATIC SURGERY
 Procedures described include Whipple, Distal pancreatectomy, central
pancreatectomy, enucleation, appleby procedure and Frey procedure.
 Similar to hepatic resections, no RCTs exist to compare open vs lap vs
robotic pancreatic resections.
 Giulianotti PC, University of Illinois, Chicago
 134 patients over 9 yrs
 Mean operating time : 331 min
 Conversion : 10.4%
 Mortality 2.23% and morbidity 26%
 Safe & feasible, with morbidity and mortality same as open surgery
Giulianotti PC. Surg Endosc. 2010

25. ROBOTIC COLORECTAL SURGERY
 Weber et al reported the first adaptation of the da Vinci system
for colorectal procedures in 2002.
 Delaney et al evaluated the perioperative outcomes for 6
matched robotic vs lap colorectal procedures.
1. Length of hospitalization, blood loss and incision length were
the same.
2. Robotic procedures were associated with increased operative
time.
 Potential benefits in cases involving rectal pelvic dissection.
 Some studies have shown positive outcomes for Total
mesorectal excision (TME) and cylindrical excision for low

26.  Greatest utilization of robotic advancements currently is centered
on TME.
 3D visualization and wristed instruments afford advantages for
nerve sparing over conventional techniques.
 Short term outcomes similar, costs higher, trends towards
improved sexual and bladder function present but without
significance.
 No clear advantage over lap for benign diseases like rectal
prolapse and complicated diverticulitis.
 Rationalized on a case to case basis ( especially narrow pelvic
anatomy, low rectal tumors or morbid obesity)

27.  Mesorectal excision for rectal cancer –
deSouza AL, Illinois, USA.
 44 patients in 4 yrs
 88.7% in mid/ lower rectum
 36 LAR & 8 APR
 LNs : median 14 (5-45)
 Circumferential margin negative in all, distal margin positive in 2.7%,
leak in 5.6%, death 2.7%
 Conversion 4.5%
deSouza AL. Dis Colon Rectum. 2010

29. Robotic vs Laparoscopic resection for rectal cancer-
ROLARR Study
(University of California, Irvine)
CONCLUSIONS AND RELEVANCE:
Among patients with rectal adenocarcinoma suitable for curative resection, robotic-assisted laparoscopic
surgery, as compared with conventional laparoscopic surgery, did not significantly reduce the risk of
conversion to open laparotomy. These findings suggest that robotic-assisted laparoscopic surgery, when
performed by surgeons with varying experience with robotic surgery, does not confer an advantage in
rectal cancer resection.

30. ROBOTIC HERNIA REPAIR
 Inguinal hernia
 Provides surgeon with more comfortable, ergonomic position than
laparoscopic approach.
 Feasible immediately following robotic prostatectomy.
Ito F. J Laparoendosc Adv Surg Tech A. 2008

31.  With the advent of robotics, larger and more complex hernia repairs are
being approached in a minimally invasive fashion.
 Benefits of fascial closure, retrorectus placement of the mesh, rectus muscle
release, and intraperitoneal suturing of the mesh are facilitated by the
minimally invasive robotic platform.

32. Comparison with laparoscopy

33. daVinci Clinical Limitations
1. No advantage over laparoscopy for cholecystectomy, splenectomy,
colectomy
2. Increased operative time
3. Open space: limitations with broad sweeping motions
4. Lack of haptic feedback while operating
5. Inability to switch instruments as well as operating field during
procedure ( problem with multi quadrant surgery)
6. Large size of the robot with bulky arms

34. Limitations/Complications
 Mechanical failure/ malfunction (0.4-4.6%)
 On/off failure
 Console malfunctions
 Robotic arm malfunctions
 Malfunctions of optic system, and
 System (software) errors
 Instrument malfunction (1.1%)
 Conversion to laparoscopy/ open (0.17%)
Won Tae Kim. Urology. December 2009

35. Recent Developments
 Decreasing size of robot – RAVEN
 Ward rounds – RP-7
 Telesurgery - Increasing distance between surgeon and
patient
 NOTES

36. RAVEN : Washington University
 Can be mounted on patient and controlled remotely

37. Robotic Rounding

38. Telesurgery along with telementoring
 Trans Atlantic Cholecystectomy by Marescaux and
colleagues
 Mentoring surgeons of Canada
Marescaux J et al. Nature 2001
Sebajang H et al. Surg Endosc 2006

39. NOTES
 Avoids wound infections, reduces pain, and improves
cosmetics and recovery times
 First transvaginal assisted cholecystectomy in US - March
2007
 First transgastric cholecystectomy in US - June 2007
 Limitations with conventional endoscope
 limited two dimensional image
 Lack of triangulation
 4 degrees of freedom
Gastrointest Endosc 2006

40. ONGOING TRIALS
 Robotic vs Laparoscopic Cholecystectomy- Outcomes and
cost analyses at University of Zurich.
 Robotic vs Laparoscopic surgery for right colon cancer-
RCT at Kyongpook National University
 Clinical and health economic impact of robot assisted
surgery vs conventional laparoscopy- A case for GBP from
IHU, Strasbourg.
 Robotic vs Laparoscopic abdominal wall hernia repair-
Assistance publique ( Hospitaux de Paris)

41. Problems to be addressed
 The pricing especially in developing countries is a
major concern.
 Training system fro surgeons.
 Following systems should be developed further
1. Image guided surgical assistant system
2. Smaller sized forceps for robots
3. Capsule endoscopic surgery
4. Training centres to be established across the world.

42. Summary
 dVSS remains the only commercially available therapeutic robotic
system .
 Telesurgery, telementoring & telepresence.
 Robotic surgery has already proven to be of great value, particularly
in areas inaccessible to conventional laparoscopy.
 Doubtful if conventional laparoscopy is replaceable in less
technically demanding procedures.
 Whether or not benefit of its usage overcomes cost remains to be
seen.
 Although feasibility shown, more prospective randomized trials
evaluating efficacy and safety must be undertaken.

43.  “It is well to remember that, in the 19th century, surgery
was thought to have reached its apogee – but the best is
yet to come.”
Fortner JG, Blumgart LH. J Am Coll Surg 2001