Lately, critics have questioned the safety and effectiveness of robotic surgery, pointing out that most of the published studies showing its efficacy are small, early and don’t show much evidence to justify the added costs. Also, there are concerns the robot may take away some of the controlled precision that comes with a live surgeon’s hands.
Amidst these concerns, Hiep T. Nguyen, MD, co-director of Children’s Hospital Boston’s Center for Robotic and Minimally Invasive Reconstructive Surgery and specialist in Urology, says that since acquiring the da Vinci ® surgical system in 2001, Children’s expertise in robotic surgery has grown. “Robotic surgery is safe, it is not experimental and it is being done every day at Children’s,” he says. “We can clearly say that robotic surgery has a lot of advantages over open surgery. It allows children to undergo surgery safely and efficiently, leads to fewer complications and helps kids recover
Children’s Robotic Surgery Center currently uses the da Vinci Si HD, a newer model that includes high definition 3D visuals and consoles for two surgeons. In response to those questioning robotic surgery, Dr. Nguyen points out that the studies used to criticize robot surgery include results from extirpative laparoscopic procedures in adult medicine. The studies aren’t about reconstructive robotic surgery in pediatrics like the ones performed at Children’s.
Robotic surgery was first used in laparoscopic procedures to remove organs. When compared to open surgery, it makes smaller incisions and allows for faster recovery. However, there were two big drawbacks: first, the use of one camera didn’t give surgeons much depth perception in the surgical area, making movement of the instruments cumbersome; and second, the actual surgical instruments were rigid, making fine control of the tools for tasks like suturing difficult.
“It was like using chopsticks to operate,” Nguyen says. “Because of that, the instruments didn’t do things like your hands would have done.” For these reasons, doctors used laparoscopy mainly for extirpative surgery rather than reconstructive surgery.
Changes in newer models improved upon these drawbacks. Robots equipped with two cameras allowed surgeons to view the target areas in three dimensions, and the introduction of ratcheted instruments mimicked the dexterity of the hands on a smaller scale, allowing a greater degree of motion and control.
These improvements gave robotic surgery the same advantages that laparoscopy has over open surgery. Robotic surgery requires smaller incisions, which allows patients to recover faster with less pain and scarring, as well as the ability to perform reconstructive surgery. And after nine years of using robots, the Children’s team has made robotic procedures comparable in time to open procedures.
Robotic surgery has an exceptionally steep learning curve. However, while surgeons usually need to perform between 10 and 20 laparoscopic simulations before becoming proficient, robotic surgery requires an average of five simulations. And while earlier studies show robotic surgery to be more time consuming than open surgery, this gap closes as surgeons gain more experience. The training program is certified by Intuitive Surgical, the manufacturer of the da Vinci.
The Robotic Surgery Center collaborates with Intuitive to develop didactics, online modules and hands-on exercises, which start out with manipulating inanimate objects and graduate to animal model surgeries. While some argue that the technique renders surgeons unaware of the physical force of their movements, the trainers teach surgeons to compensate by using visual feedback to guide their maneuvering instead. Visual cues include the blanching of tissues and visible tension in sutures.
In the interest of improving surgical techniques, Children’s Robotic Surgery Center conducts translational research focused on supplemental technology, expanding the breadth of robotic surgery procedures and new instrumentation. The team currently uses molecular imaging to create selective viewing of different tissues, such as tumor cells, fat, solid organs and lymph nodes, thus making surgical procedures more targeted.
Doctors in the Robotic Surgery Center would like to conduct fetal surgery procedures using the robot, a strategy that could correct congenital conditions in utero at minimal risk to mother and child. Any fetal surgery exposes both the mother and the fetus to morbidity, but the smaller incisions required by robotic surgery may reduce the likelihood of infections and premature labor.
The Robotic Surgery Center also collaborates with the United States Army to develop surgical robots for the field.
More information: 617-355-7796 or childrenshospital.org/robotics