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The new surgical assistant at the University of North Carolina Hospitals arrived in February sporting three arms, a computerized brain and a glowing track record in helping to repair heart valves, remove cancerous prostates, bypass blocked coronary arteries and perform gastric bypass operations for morbid obesity.

The new arrival is a robotic machine, the da Vinci Surgical System, manufactured by Intuitive Surgical. UNC currently is the only gynecological oncology program in the Southeast that is using it.

The robot has been used successfully at UNC for prostate removal surgery; for hysterectomies for endometrial and cervical cancers; and for pediatric gallbladder removal and stomach surgery to prevent gastric reflux.

The robotic system gained federal government approval for gynecological use in April.

"We've found the robotic operation to be more precise than conventional surgery, and it allows a patient to return to normal activities much more quickly, with a shorter hospital stay. We also found a reduced use of pain medications after robotic surgery, with fewer complications," said Dr. John F. Boggess, gynecological oncologist, assistant professor of obstetrics and gynecology at UNC's School of Medicine and a member of the UNC Lineberger Comprehensive Cancer Center.

Boggess is the first physician statewide to be certified to perform gynecological procedures with the robotic system.

In robotic-assisted surgery, the da Vinci robot is an extension of the surgeon's hands in a way not previously possible with minimally invasive surgery via laparoscopy, he said.

"And that's the key to its success," Boggess added. "The robot takes us a big step beyond traditional laparoscopy. It allows us to operate more naturally, the way we do in open surgeries, but still preserve a minimally invasive approach with small incisions."

As in laparoscopy, robotic surgery involves small incisions of one-fourth to three-fourths of an inch, into which sleeves are inserted as ports for placement of specialized instruments and a video camera.

"Robotic surgery allows us to virtually place our hands inside the patient without the need for large incisions," Boggess said.

After sleeve placement, the robot, much like a post with three arms, is wheeled over and its center arm docked to a port that holds the camera and the other arms docked to the instrument ports.

However, surgery with the da Vinci does not mean close proximity to the patient. Unlike with laparoscopy, the surgeon is seated across the room from the patient, with arms inserted into the nearby console, fingers on stirrup-like holders and eyes fixed on lenses for sharp magnified images of the surgical site. Focus is adjusted via foot pedals.

While laparoscopy allows manipulation of instruments up, down and side-to-side, surgery with the da Vinci allows more natural wrist movement.

The robot's arms have wrists with eight degrees of freedom that allow the surgeon "to bend around corners and work in ways that are much more natural," said Boggess. This allows full range of motion and the ability to rotate instruments 360 degrees through tiny incisions. Direct and natural hand-eye instrument alignment is similar to open surgery, with "all-around" vision and the ability to zoom in and out.

Another advantage with da Vinci is the elimination of tremor. Surgeons can scale, or ratio, their finger movement to that of the robotic instrument. A movement of inches at the console can be scaled down to centimeters in the patient.

"This can re-introduce precision in an elderly surgeon, who has all those years of experience but has lost some dexterity," Boggess said.

Dr. Daniel von Allmen, chief of surgery at the N.C. Children's Hospital and associate professor of surgery at UNC, has performed several successful pediatric operations with the da Vinci robotic system and said the scalability was a major advantage.

"This is very important in pediatric surgery, given the smaller space to operate, and for performing refined interventions very precisely," he said, adding that "the ultimate potential for the system, if the instruments can be made small enough, would be its use in fetal surgery, in utero."

Since the arrival of the da Vinci robot at UNC Hospitals in early 2005, several successful "robotic-assisted laparoscopic radical prostatectomies," or RALRPs, have been completed.

The robot is a better tool and an improved instrument compared to what has been used previously, said Dr. Eric M. Wallen, assistant professor of urologic surgery, director of urologic laparoscopy at UNC Hospitals and a UNC Lineberger member.

"I expect that over the next decade, RALRP will become the most common surgery performed for patients with prostate cancer. The robot improves the view that the surgeon has, and its instruments have more flexibility to perform the delicate nerve sparing and sewing parts of the procedure," he said.

Patients, in turn, recover quickly and are able to resume their normal life within days of major surgery instead of months, Boggess said.

"The robot provides the laparoscopic surgeon with a degree of precision and safety not achievable with traditional surgery or laparoscopy and will redefine abdominal/pelvic surgery for the next generation of surgeons," he added.


Source:American College of Physicians

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