The first fully-robotic system was approved for clinical use in the USA in 2000. Amazingly that is now almost two decades ago. The last 10 years has seen an explosive growth in the use of robots particularly in the USA but increasingly in Australia. Urology surgeons led the way finding it increasingly useful to perform prostate removal for cancer. The prostate is in a confined space and the procedure requires lots of suturing. Even though this can be done via laparoscopy it is extremely difficult and the robot has revolutionised the procedure offering men a minimal access procedure with probably lower complications and faster return to normal activities whilst maintaining similar long term survival benefits. Multiple other clinical specialities have found innovative and beneficial methods of using robots to assist with surgical procedures. These include avoiding the necessity to cut the jaw in half for debilitating traditional surgery at the base of the tongue and the avoidance of massive incisions to remove lymph nodes adjacent to the aorta and major vessels for certain cancers.
Robots have been used increasingly in the USA for gynaecological procedures, now representing one of the major uses for the robot. The last few years has seen an increasing uptake in Australia.
There has been significant controversy regarding the use of robots in surgery. Within a gynaecological context it has been suggested that they are incredibly expensive and don’t seem to offer significant benefits. At this stage of the debate there are not large amounts of clinical data demonstrating clear benefit. I was initially sceptical of their use and considered they were likely to be very expensive training tools for early stage surgeons. I felt my laparoscopic surgical skills were such that I could do whatever I needed without an expensive “unproven” robot. Despite that I also realised that technology advances and also gets cheaper. I therefore started training as a robotic surgeon. Having now performed over 50 cases I am simply amazed at the technology and my initial scepticism has been completely replaced by enthusiasm. There is no doubt a learning curve although experienced surgeons are likely to get through this fairly rapidly. The view with 3 dimension cameras is simply extraordinary and you get the feeling you are actually inside the patient, only a tiny distance away from the target surgical site. The stability of the platform is surreal with no movement and an incredible capacity to dissect out tiny structures. I am unsure what it is but the robot assists finding surgical planes with an extraordinary degree of ease that simply does not happen with traditional surgical techniques. As a consequence for many procedures bleeding becomes a non-issue with virtually bloodless fields.
My fourth case was the removal of a fibroid adjacent to the lining of the uterus and I had never seen such a pristine view of the outer endometrium before. The view was such that we were able to keep the area intact. The next case involved a poor woman with severe pain and an endometriotic mass invading into the bladder. The robot easily allowed us to remove the nodule with a portion of the bladder and repair the defect much faster than we would normally have done traditionally. After these early cases I was rapidly becoming converted. Two weeks ago I operated on a lady who had come from another hospital where they appreciated she had significant endometriosis and were considering a segmental bowel resection. When we assessed the situation it was rapidly obvious that she also had an almost completely blocked right kidney tube and partial blockage of the left side also. The robot allowed me to do an amazing dissection of the right uterine artery, removing the endometriotic nodule without needing to remove any of the kidney tube or reimplant it back into the bladder which would often be required. As it was we just needed to shave the rectum and not perform a bowel resection. My very experienced colorectal colleague who came into watch what we were doing stayed marvelling at the dissection the robot enabled us to do.
It is also notable how much easier it is on the surgeon with robotic assistance. After traditional long complex surgeries I would come home feeling as though I had run a marathon. I don’t get that feeling now and can only assume that during the case robotics assists with ergonomics, fatigue and focussed concentration.
I am absolutely convinced this is the future particularly for advanced surgical problems. The view, stability and dissection capacity can only improve outcomes and decrease complications. Large scale data from the urological literature is starting to confirm this and I believe it is only a question of time before the same occurs with gynaecological surgery. Since endometriosis can be so difficult and challenging to deal with, I am sure these are the exact cases that will benefit from robotic assistance.
There is also no question that the technology will evolve such that we will soon have single port site access with only one small incision in the umbilicus and it will inevitable become cheaper.
Assessment of surgical procedures is exceedingly difficult as there are so many factors at play including the skill and experience of the surgeon. The robot will assist with this and already I think I am a better laparoscopic surgeon as a consequence of using the robot.
I am not in the camp of the skeptics anymore. I see a bright future with the robot and many positive benefits for both patients and surgeons.
Multiple other clinical specialities have found innovative and beneficial methods of using robots to assist with surgical procedures. These include avoiding the necessity to cut the jaw in half for debilitating traditional surgery at the base of the tongue and the avoidance of massive incisions to remove lymph nodes adjacent to the aorta and major vessels for certain cancers.
Robots have been used increasingly in the USA for gynaecological procedures, now representing one of the major uses for the robot. The last few years has seen an increasing uptake in Australia.
There has been significant controversy regarding the use of robots in surgery. Within a gynaecological context it has been suggested that they are incredibly expensive and don’t seem to offer significant benefits. At this stage of the debate there are not large amounts of clinical data demonstrating clear benefit. I was initially sceptical of their use and considered they were likely to be very expensive training tools for early stage surgeons. I felt my laparoscopic surgical skills were such that I could do whatever I needed without an expensive “unproven” robot. Despite that I also realised that technology advances and also gets cheaper. I therefore started training as a robotic surgeon. Having now performed over 50 cases I am simply amazed at the technology and my initial scepticism has been completely replaced by enthusiasm. There is no doubt a learning curve although experienced surgeons are likely to get through this fairly rapidly. The view with 3 dimension cameras is simply extraordinary and you get the feeling you are actually inside the patient, only a tiny distance away from the target surgical site. The stability of the platform is surreal with no movement and an incredible capacity to dissect out tiny structures. I am unsure what it is but the robot assists finding surgical planes with an extraordinary degree of ease that simply does not happen with traditional surgical techniques. As a consequence for many procedures bleeding becomes a non-issue with virtually bloodless fields.
My fourth case was the removal of a fibroid adjacent to the lining of the uterus and I had never seen such a pristine view of the outer endometrium before. The view was such that we were able to keep the area intact. The next case involved a poor woman with severe pain and an endometriotic mass invading into the bladder. The robot easily allowed us to remove the nodule with a portion of the bladder and repair the defect much faster than we would normally have done traditionally. After these early cases I was rapidly becoming converted. Two weeks ago I operated on a lady who had come from another hospital where they appreciated she had significant endometriosis and were considering a segmental bowel resection. When we assessed the situation it was rapidly obvious that she also had an almost completely blocked right kidney tube and partial blockage of the left side also. The robot allowed me to do an amazing dissection of the right uterine artery, removing the endometriotic nodule without needing to remove any of the kidney tube or reimplant it back into the bladder which would often be required. As it was we just needed to shave the rectum and not perform a bowel resection. My very experienced colorectal colleague who came into watch what we were doing stayed marvelling at the dissection the robot enabled us to do.
It is also notable how much easier it is on the surgeon with robotic assistance. After traditional long complex surgeries I would come home feeling as though I had run a marathon. I don’t get that feeling now and can only assume that during the case robotics assists with ergonomics, fatigue and focussed concentration.
I am absolutely convinced this is the future particularly for advanced surgical problems. The view, stability and dissection capacity can only improve outcomes and decrease complications. Large scale data from the urological literature is starting to confirm this and I believe it is only a question of time before the same occurs with gynaecological surgery. Since endometriosis can be so difficult and challenging to deal with, I am sure these are the exact cases that will benefit from robotic assistance.
There is also no question that the technology will evolve such that we will soon have single port site access with only one small incision in the umbilicus and it will inevitable become cheaper.
Assessment of surgical procedures is exceedingly difficult as there are so many factors at play including the skill and experience of the surgeon. The robot will assist with this and already I think I am a better laparoscopic surgeon as a consequence of using the robot.
I am not in the camp of the skeptics anymore. I see a bright future with the robot and many positive benefits for both patients and surgeons.
