Robotic Surgical System Lends a Hand

From OncoLog, October 2006, Vol. 51, No. 10

Robotic Surgical System Lends a Hand

by Ellen McDonald, Ph.D.

Whether or not they are acquainted with terms like “laparoscopic radical prostatectomy” or “laparoscopic radical hysterectomy,” most patients definitely know they would prefer a surgery that will cause the least amount of pain and scarring and have the shortest recuperation time. For their part, surgeons generally prefer procedures that require the smallest incisions, involve a negligible possibility of infection, cause minimal blood loss, and offer improved speed and efficiency.

While traditional, open surgery is still a mainstay of cancer treatment, minimally invasive techniques such as laparoscopy have taken on an increasingly important role in the past few years, thanks to quicker recovery times and comparable outcomes. At The University of Texas M. D. Anderson Cancer Center, robotic surgery with the new da Vinci Surgical System has brought further improvements in precision and simplicity to laparoscopy, allowing it to be used in more complex procedures. Surgeons at M. D. Anderson are using the new system in laparoscopic hysterectomies and prostatectomies now, and it will soon be used in some bladder and endometrial cancer surgeries as well. Robotic surgery has many more potential applications in cancer treatment, particularly for thoracic and cardiac procedures.

Better-than-human precision

In contrast to standard laparoscopic equipment, this 1,400-pound, four-armed “robot” offers surgeons several advantages, including better control, dexterity, and visualization. At a console a short distance from the patient, the surgeon views a real-time, highly magnified three-dimensional image of the surgical site—as opposed to the two-dimensional image available with a laparoscopic television monitor. From this improved vantage point, the surgeon operates controls at the console, and those movements are replicated with better-than-human precision by the robotic arms at the bedside.

“Although it’s called a robot,” noted John W. Davis, M.D., an assistant professor in the Department of Urology, “the da Vinci system is actually more a flexibly wristed precision instrument that replicates what the surgeon’s hands do and filters out any tremors, allowing the surgeon to make very precise motions in the patient’s body.

“The da Vinci system is particularly useful for prostate surgery, which takes place low and deep in the pelvis,” Dr. Davis continued. “The surgical margin between the prostate and the cancer is very small, only a few millimeters, and there are important quality-of- life outcomes associated with a technically successful surgery in terms of preserving sexual function and urinary function.”

Dr. Davis noted that the system will soon be used for radical cystectomies in bladder cancer for similar reasons. “We expect it to be most useful in complex bladder procedures in which the technological precision helps with intricate reconstructive elements such as sewing the bladder to the urethra,” he said. “In contrast, a procedure like kidney removal, which has no reconstructive element, can be performed very well through standard laparoscopy.”

Pedro Ramirez, M.D., an associate professor in the Department of Gynecologic Oncology, is equally impressed by what he calls this “amazing” technology. “It is remarkable to see a surgeon’s fingers moving in one part of the room and the instrument translating those exact movements inside the patient.” He and his colleagues are currently using M. D. Anderson’s da Vinci Surgical System for advanced gynecologic procedures such as laparoscopic hysterectomies for uterine cancer.

Meeting demand

The da Vinci system is expected to allow surgeons to meet the rising demand for minimally invasive procedures more rapidly, because the transition from open surgery to robotic surgery is much easier than the transition from open surgery to traditional laparoscopic surgery. “The robot basically enables surgeons to perform laparoscopy without the steep learning curve associated with standard laparoscopy,” observed Surena Matin, M.D., an assistant professor in the Department of Urology.

Another advantage of the da Vinci Surgical System is the improved ability to record surgeries, thanks to the stability of the robotic arm guiding the camera into the incision. “We can videotape our cases and later refer back to a particular step when correlating pathologic outcomes with how the case went,” continued Dr. Davis. “This high quality record makes it easier for surgeons to teach their techniques and skills to fellows and other faculty. In this way, I believe the robotic system will allow us to approach surgeries such as prostatectomies in a very reproducible manner and achieve consistent outcomes.”

Traditionally, surgery to remove a cancerous growth has meant a large incision and a lengthy recovery time. The advent of laparoscopic surgery has changed that for many cancer patients, and robotic surgery looks to be the next major step forward in the arena of minimally invasive surgery.

“Of course, promising new technologies like the robotic system don’t mean the end of open surgery,” said Dr. Matin. “Open surgery will continue to play an important role, particularly in advanced cancers.”

“Technology changes fast, and it’s hard to predict where we’ll be in regard to minimally invasive procedures 20 years from now,” added Dr. Ramirez. “But robotics is in its infancy, and I know for certain we aren’t even close to reaching the peak potential for these procedures.” Like many other surgeons, Dr. Ramirez is curious to see where robotics will ultimately fit as a tool in surgical oncology. But he points out that, from the patient’s point of view, the surgeon’s means aren’t nearly as important as the end.

“Generally speaking, what patients want are small incisions and a good outcome,” he said. “Robotic surgery is allowing us to offer that to more and more of our patients.”

Evaluating New Surgical Technologies

With an eye toward future technological advances and new laparoscopic procedures, surgical faculty at M. D. Anderson Cancer Center formed the Minimally Invasive New Technology in Oncologic Surgery (MINTOS) program.

“The program began with a group of surgeons and other faculty from different oncologic specialties who were interested in evaluating the latest technologies for minimizing the trauma caused by traditional surgery,” said Dr. Matin. “The idea was to come together as a group and evaluate promising new technologies in a randomized way, in a controlled setting, just as we evaluate new drugs. Only such scientifically grounded information can truly validate the purchase of new, and extremely expensive, equipment. The MINTOS program provides an infrastructure for such evaluations.”

Although its initial focus has been on improving patient care with innovations such as the da Vinci system, the MINTOS program is also committed to improving training in minimally invasive surgery. To that end, more than 50 M. D. Anderson surgical trainees and faculty participated in a MINTOS program–sponsored training session this year that included the opportunity to hone their skills in a laboratory featuring a virtual reality surgical simulator. Plans are to further expand the training program by sponsoring courses and presentations by experts in the field and by establishing a dedicated laboratory space for training.

For more information on this topic or for questions about M. D. Anderson’s treatments, programs, or services, call askMDAnderson at (877) MDA-6789.

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