Robotic GI surgery

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 - three arm movements (in out, up down, side to side), three wrist movements (side to side, up and down, roll) and 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 Surgical console, Patient cart, and 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 Integrate left and right optical channels for stereoscopic vision 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

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

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

14. 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 Both lap and robotic safe and low complication rates. However no clear benefit seen in robotic group.

15. 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 No distinct advantage offered by robot aside from increased operative time. Owen et al (2013) at University of Nebraska reported similar outcomes except increased cost.

16. 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

17. 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 LN harvest did not differ significantly. Robotic surgery associated with less blood loss. Shorter hospital stay with robotic surgery. Morbidity 9-30% and mortaliy 0-9% in literature.

18. 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

19. 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.

20. 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 Added degrees of freedom Ambidextrous suture placement However paucity of data comparing the two approaches.

21. 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

22. 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.

23. 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

24. 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. Length of hospitalization, blood loss and incision length were the same. 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 rectal cancers.

25. 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)

26. 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

27. 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.

28. 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

29. 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.

30. Comparison with laparoscopy

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

32. 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

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

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

35. Robotic Rounding

36. 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

37. 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

38. 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)

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

40. 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.

41. “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