Robotic Surgery Enters a New Era

Michael Stifelman, M.D., Chair of Urology and Director of Robotic Surgery, Hackensack Meridian Health, Hackensack University Medical Center
Michael Stifelman, M.D., Chair of Urology and Director of Robotic Surgery, Hackensack Meridian Health, Hackensack University Medical Center

Michael Stifelman, M.D., Chair of Urology and Director of Robotic Surgery, Hackensack Meridian Health, Hackensack University Medical Center

It seems like every hospital these days has a surgical robot, and often more than one. During robotic surgery, doctors use very small surgical instruments that fit into a patient’s body through incisions less than a half-inch long. In conventional robotic surgical systems, these instruments are mounted on three robotic arms, giving the surgeon maximum range and precision of motion during the surgery. A fourth arm holds a high-definition, three-dimensional camera that magnifies images from inside the body up to 10 times. Today, creative innovations are expanding the applications of robotic surgery to parts of the body once deemed inaccessible using traditional systems.

The Benefits of the Robotic Approach

The advantages of robotic surgery may include:

•  Smaller incisions
•  Increased precision
•  Decreased blood loss
•  Less risk of infection
•  Reduced postoperative discomfort
•  Shorter hospital stay
•  Faster recovery and return to normal activities

 Today, creative innovations are expanding the applications of robotic surgery to parts of the body once deemed inaccessible using traditional systems.  

Urology is a field with a great deal of experience with robotic surgery, which enables urologists to visualize and work around vital nerves and blood vessels while performing prostatectomy (removal of the prostate gland), partial nephrectomy (removal of a tumor from the kidney while maintaining function), cystectomy (removal of the bladder) and repair of urinary structures such as the ureters — among many other procedures. Gynecologic surgeons often use the robotic approach to perform hysterectomies, lymph node dissections  other procedures, and some orthopedists use special robotic devices to enhance the precision of knee replacements. Clearly, the technology has taken off and is today used in many other specialties, including general surgery; cardiothoracic surgery; colorectal surgery; Ear, Nose and Throat (ENT) procedures; and Gynecologic Oncology. There are also robotic platforms used in orthopedics and spine surgery.

Operating Through a Single Incision

One of the most recent advances in robotic surgery technology is the development of a single-port system, enabling the surgeon to perform the entire operation through a one inch-wide incision. This novel device will make it possible for more complex operations to be completed robotically, especially procedures that need to be performed in a very narrow space. Conventional four-arm robotic systems cannot fit in small spaces such as the rectum and can be difficult to manipulate in the upper airways or digestive tract. The single-port system may open new doors to robotic applications for those types of surgeries.

Here’s how it works. A single narrow tube (cannula) contains four instruments that the surgeon uses to perform the operation: three sets of elbowed “grasping” instruments that the surgeon can control with exceptional precision to make incisions, remove tissue, insert sutures and a lighted magnifying camera to visualize the surgical field. The device can extend up to nine and a half inches into the surgical field. The U.S. Food and Drug Administration (FDA) has approved the single-port robotic surgical system for urologic procedures and ENT procedures.Urologists are already developing new techniques with the technology including:

•   Extraperitoneal prostatectomy, inserting the cannula through an incision in the navel and into the pelvis to remove the prostate.

•   Intravesical prostatectomy to remove an enlarged prostate through an incision just above the pubic bone, inserting the cannula through the bladder to reach the prostate.

•   Perineal radical prostatectomy, removing the prostate through the perineum (band of skin between the scrotum and rectum), an area once considered too narrow to enter using conventional robotic instruments.

•   Repair of the ureter in young women with congenital blockages or narrowing of these tubes connecting the kidneys with the bladder, operating through a navel incision.

Because of the ability to work in a narrow, deep space, colorectal surgeons have an interest in applying the technology to trans-anal minimally invasive surgery (TAMUS.)The patient leaves the operation with no external incisions. Similarly, head and neck surgeons insert the single-port system through a patient’s mouth to remove a cancerous larynx, pharynx or esophagus more easily than they can with the four-armed unit.

New Robotic Systems and Applications

Multiple manufacturers are entering the robotic surgery arena by designing innovative systems for certain types of procedures. There are now special robotic systems available for brain surgery, spine surgery, bronchoscopy guidance and joint replacement. Digital 3D imaging and other enhanced imaging technologies are further leveraged in computer assisted surgery to perform procedures more efficiently and safely.

For example, surgeons can use a novel virtual reality system to overlay a patient’s MRI or CT image on the organ to be operated on to localize blood vessels and critical structures, providing a roadmap and allowing the surgeon to literally see through the patient to complete the procedure as effectively and safely as possible. Near-infrared(NIR) fluorescence imagingenables the visualization of blood flow, abnormal lymph nodes and ureteral anatomy.  

Under investigation is the process of creating molecules that can be injected intraoperatively which allow the surgeon to “light up” nerves, or cancer cells in an organ allowing the surgeon to clearly seewhat to remove and what to leave in place. In essence, letting us “remove the bad while sparing the good.”

As surgeons consider the many more operations they may be able to perform using the latest robotic technologies and innovations, the possibilities are endless.