Clinical Practice

Most practicing surgeons have already seen at least one significant revolution during their careers, the radical changes brought by the many discoveries of the Information Age. The most dramatic has been the shift to minimal access surgery (laparoscopic, endoscopic, etc). The surgeon of the near future will be trying to decide (just as was the case with the introduction of laparoscopic surgery) whether it will be necessary to train and practice with robotic surgical systems. Surgeons already have multiple options— open surgery, laparoscopic, endoluminal, endovascular, percutaneous, and so on. The answer to robotic surgery is an unequivocal yes.

Current view of robotic surgery is that the robot is used to enhance the performance of the surgeon—either through more precise motions or through providing access to very restricted places. While this is true, the real value of robotics is that it brings surgery completely into the Information Age. Open surgery is Industrial Age, with directly looking and feeling the organs and directly moving the tips of the instruments. Laparoscopic surgery is a transition: half in the Industrial Age—still directly moving instrument tips—and half in the Information Age—looking at the monitor with the electronic image (information) of the organs, not looking at the organs themselves. Robotics makes the transition to the Information Age complete by looking at information (the monitor) and manipulating information (hand motions send electronic signals that control the tip of the instruments). It is not longer blood and guts, it is bits and bytes.

This is a profound revolution, because it is now possible to integrate the entire surgical care of a patient with information science right at the surgical console of a robotic surgery system (Fig. 1). From the console, the surgeon can perform open surgery or laparoscopic surgery, can remotely operate with telesurgery, can rehearse a specific surgical procedure on a patient-specific three-dimensional image derived from the patient's computed tomography scan, can integrate the image during surgery with image-guided surgery to give the surgeon "X-ray vision," and can practice and train on the console using virtual reality surgical simulation. Thus from preoperative planning to specific surgical procedure rehearsal, to open or laparoscopic or interventional procedure, to training (for new procedures) all components become a single, seamless continuity for patient care. Although not yet implemented, the surgeon's hand motions can be recorded and archived as proof of proficiency on a continual basis (instead of periodic recertification).

Next generation robotic systems will also incorporate automatic tool changers (instead of scrub nurse to change the instruments) (Fig. 2) and automatic supply dispensers (instead of the circulating nurse) for suture, gauze, etc. Soon the surgeon will become a solo-surgeon in the truest sense of the word, controlling the entire operation from the console. Because there will be no people assisting the robot (the three systems together are called a "robotic cell"), the surgeon can sit at the console just outside of the operating room (looking through a glass window), and there will be no people in the operating room. Every time a tool is changed or a supply is dispensed, three actions immediately occur: The patient is billed, the tool or supply is restocked, and an order is

FIGURE2 ■ Penelope-the robotic scrub nurse. Source: Courtesy of Michael Treat, MD, Columbia University, New York, New York.

FIGURE 1 ■ Integrating surgery with surgical robotics. Source: Courtesy of Joel Jensen, SRI International, Menlo Park, California.

FIGURE2 ■ Penelope-the robotic scrub nurse. Source: Courtesy of Michael Treat, MD, Columbia University, New York, New York.

FIGURE3 ■ The force reflecting grasper. Source: Courtesy of Blake Hannaford and Jacob Rosen, University of Washington, Seattle, Washington.

FIGURE3 ■ The force reflecting grasper. Source: Courtesy of Blake Hannaford and Jacob Rosen, University of Washington, Seattle, Washington.

sent to inventory control to order a new tool or supply—all within 50 msec with 99.99% accuracy (which is the current industry standard). The result is clearly a dramatic improvement in performance and efficiency, as well as cost saving.

Another change in robotic systems is that they are incorporating new types of tools. By using micro-electro-mechanical system technology, tiny sensors can be inserted into the instruments to measure pressure, forces, etc. (Fig. 3) to provide for the surgeon the sense of touch (2), not only mimicking what the surgeon would actually feel, but also providing delicate touch beyond what is possible with the human fingertip.

There will also be an entire new tool-set for the surgeon of the future. Although the scalpel will still be required, many other modalities will be used. The trend is from mechanical instruments (of the Industrial Age) to energy-directed instruments (of the Information Age). Surgeons have begun using lasers, and next generation systems will employ high intensity focused ultrasound, thermal-directed systems (brachytherapy and cryotherapy), microwave instruments, and femtosecond lasers. These systems will require a complete rethinking of what it means to be a surgeon. The high intensity focussed ultrasound concentrates two beams of ultrasound at a distance, in this case inside the body. Early clinical trials are being conducted in breast, prostate, and liver tumors to completely coagulate or vaporize them from external high intensity focussed ultrasound system. In addition, animal trials have been successful in stopping bleeding from the liver and spleen transcutaneously (3). Thus surgeons will have to begin thinking about performing surgical procedures without entering the body or using a scalpel. There is also significant progress with femtosecond lasers. These new lasers are totally different from those used today—they release their energy in 10~15 seconds. The result is that it is possible to create a hole in the cell membrane without injury to the cell. This allows optical tweezers (another form of laser) to enter the cell and manipulate individual organelles, such as Golgi bodies or mitochondria. Additional progress is being made on entering the nucleus and directly manipulating the DNA. The significance is that the surgeon of the future may not be removing organs or tissues but rather using a microscope and laser rearrange the DNA inside the cell to change the fundamental biology—this is referred to as biosurgery (4).

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