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Guy Vallancien

Institut Montsouris, Université Pierre et Marie Curie, Paris, France

The positive experience in robotic laparoscopy, presented by the Detroit group, demonstrates the evolution of surgical telemanipulation systems to benefit the surgeon. For instance, during laparoscopic radical prostatectomy, the reanastomosis of the bladder neck to the urethra occurs at the end of the surgery. At this point, the surgeon is often tired, and it becomes more challenging to execute intracorporal sutures. The execution of these sutures, however, is facilitated by the telemanipulation arms of the robot. The robotic arms provide six degrees of freedom, which allows an enormous flexibility in the "wristed arms." This flexibility allows the surgeon to place his needle in virtually any position, without the usual attention required in needle placement in the needle driver. Laparoscopic surgery, furthermore, can be physically exhausting when the surgeon stands next to the operating table for long periods of time. With the robot sitting at the control console, comfort is increased. One can extend this thought by stating that a more comfortable surgeon may execute a better operation. Nevertheless, robot-assisted laparoscopic prostatectomy does not provide any additional benefit to the patient. When comparing traditional laparoscopic prostatectomy to robot-assisted laparoscopic prostatectomy, a tour center, the only significant difference is a greater blood loss with robotic assistance.

What is the future of telemanipulation? I do not believe that teletransmis-sion will be viable in a center where there is not a large volume of cases. Clearly, to acquire such equipment, the center must already be an important referral center with resources available to acquire current technology. Nevertheless, there is a growing interest in robot-assisted surgery, and this interest is attributable to two main reasons:

1. To train young surgeons in surgery and to expose them to difficult cases. As an analogy, the cockpit simulator of an Airbus A320 is extremely realistic. The most dangerous situations are programmed into the computer; and young pilots are trained through simulated events. Similarly, young surgeons will soon be able to learn operations and practise them multiple times, without operating on living patients.

2. The concept of the industrial revolution in medicine. In the future, laparo-scopic prostatectomies can be performed in a large operating room of 250 m2, equipped with four robots. At the Institut Mutualiste Montsouris, we have a laparoscopic prostatectomy training program for scrub nurses. Currently, we do laparoscopic prostatectomies with only a scrub nurse at the operating table. This nurse prepares the patient, handles the robotic instruments, and assists the surgeon with the suction and forceps. At Montsouris, our resident controls the robot and the staff surgeon observes the operation. Our vision is to have four trained laparoscopic nurses and four residents, in this specialized setting, performing laparoscopic prostatectomies simultaneously. One staff surgeon would visit each console or, even with a fifth console, help the residents when required, for instance, in the dissection of the neurovascular bundles or the prostatic apex or in completing a difficult anastomosis. Such an evolution may also minimize long-term costs, because only one anesthetist and circulating nurse would be required for all four operations. Thus, technology has shifted the era of the surgeon as artist to the era of industrial surgery.


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