Robotics Versus Human Golden Fingers in Gynaecological Endoscopy

Robotics Versus Human Golden Fingers in Gynaecological Endoscopy

L. Mettler

Department of Obstetrics and Gynaecology, University of Kiel, Germany

Summary

The objective of the study was to compare the traditional vaginal laparotomy and radical hysterectomy techniques with different kinds of endoscopically assisted or total endoscopic hysterectomy techniques. The golden fingers used in vaginal surgery and at laparotomy are assisted in endoscopic surgery by instruments without tactile feeling but dependent upon the subjective course movements and intelligent fingers of the surgeon. Computerised documentation has gained ground in gynaecological endoscopy and even robots no longer belong just in the realm of science fiction but perform specialised tasks in certain fields. The aim of this study was a comparison of robotic versus human laparoscopic camera control in 60 cases of laparoscopic assisted vaginal hysterectomy. Methods: Utilising robotic technology a robot has been designed specifically for the purpose of holding and manoeuvring the laparoscope under the direct control of the surgeon. We tested AESOP 3000 = Automated Endoscopic System for Optimal Positioning in 45 patients who underwent a classic intrafascial supracervical hysterectomy and in 15 patients undergoing routine laparoscopic assisted vaginal hysterectomies (LAVH). Results: The elimination of the camera holder allows two doctors to perform complex laparoscopic surgery faster than without the robotic arm. The average length of the hysterectomy procedure performed by surgeons using the AESOP voice control was 50 minutes for the CISH technique and 70 minutes for the LAVH. The length of the surgical procedures was compared to similar operations without the AESOP support arm and revealed a time save of at least 15 minutes. Conclusion: The voice-controlled AESOP also works in hysterectomy procedures more efficiently and faster than the hand or foot controlof the samedevice and certainly faster than a camera held by an assistant. Human golden fingers employed only to hold a camera in gynaecological surgery are better replaced by robotic control. I envisage tactile instruments working together with robotic camera control in an ideal way in the forthcoming millennium.

Introduction

Over the last two decades minimally invasive surgery has become increasingly popular and has been demanded by both surgeons and patients. Its benefits lie predominantly in reducing pain and providing a more rapid recovery for patients compared to traditional surgery. Today many advanced techniques are being performed in gynaecology, urology, cardiac surgery, brain surgery, orthopaedic surgery as well as in general surgery. To control the surgeon’s visual field it is either necessary for the surgeon to hold the laparoscope and camera attachment or rely on assistance. At present and in the imminent future improvements in efficiency and safety in minimally invasive surgery will include the disciplines of robotics, computer assistance, 3-D optics and mechanics. The benefits of sophisticated technologies will be measured by factors such as shortened operating times, improved outcomes, lesser morbidity, diminished use of personnel and elimination of other instrumentation. Utilising robotic technology offered by a company in Santa Barbara, USA called Computer Motion a robot has been designed for endoscopic surgeons specifically for the purpose of holding and manoeuvring the laparoscope under the direct control of the surgeon. AESOP (Automated Endoscopic System for Optimal Positioning) has been tested in a variety of laparoscopic procedures and has already proved to perform at least as well as if not better than a human assistant in terms of camera holding with less erroneous camera motion and accidental contacts of the endoscopic lens with internal organs. Robotic control of the laparoscopic camera scope and visual field has improved efficiency and shortened operative procedures in minimally invasive surgery. About a year ago voice control of the robotic arm became clinically available and has been used successfully. AESOP offers the possibility of hand control, foot control and voice control.

Material and Methods

The Automated Endoscopic System for Optimal Positioning (AESOP) from Computer Motion Inc. of Goleta, California is holding and moving the laparoscope during surgery (Harding, 1994; Kavoussi et al. 1995; Geis et al. 1996; Garcia, 1996). The surgeon can direct the articulated metal arm by means of a foot pedal or hand control or using the voice control. In addition, laparoscopic views can be keyed in for return visits by using the memory feature which is available for three positions. With smooth

Table 1. Robotic arm used in 60 gynaecological hysterectomies. A comparison between CISH and LAVH. Times are rounded up to the nearest 5 minutes and comprise the whole preoperative preparation time after the anaesthetised patient has been rolled into the operation theatre, including the time taken to fix and set-up the robotic tool.

The elimination of the camera holder allows two gynaecologists or one gynaecologist and a nurse to perform complex laparoscopic gynaecological surgical procedures, such as hysterectomies using the Classic Intrafascial Supracervical Hysterectomy technique (Semm 1991) and the laparoscopic assisted vaginal hysterectomy (Reich 1989). The use of the robotic arm to hold the laparoscope and camera along with its ability to provide an absolutely steady visual field increases the concentration and efficiency of the surgeon. As the application of the hand piece limits the surgeon to using the two arms for the laparoscopic procedure, foot control seems more preferable; however, in our experience this procedure takes longer than the voice control (Mettler et al. 1998). The robot with the voice control enables us to ask the robotic arm to move up; down; left; right; in; out; to save one, two and three pictures and return to these pictures. It allows a safer and more secure movement of the scope. Data specified in Table 1 demonstrate the increase in the operating time of the procedure if performed in the conventional way. Certainly less fogging and smudging of the scope lens was observed. As a result the requirement to clean the optic in heated water (50÷ C) during the procedure was not given. The studies demonstrate clearly trends in favour of voice control and the use of the robotic arm rather than a human arm.

Discussion

Of course the golden fingers of laparotomic surgeons never existed, they are a dream of all doctors. We know that even the movements of our fingers depend on many subjective motions of the moment. Laparoscopic surgery has introduced smaller openings into the abdomen and a larger visual field but has taken away the tactile sense of our fingers. Modern technology has developed instruments with multiple degrees of liberty and robotic devices.

References

Garcia Clinical Utility of a Robotic Assistant During Laparoscopic Cholecystectomy. 8th Annual International Conference of the Society for Minimal Invasive Therapy, Como, Italy, Sept. 16-20th, 1996

Geis, P., McAfee, P., Kim, C., Brennan, E. Robotic Arm Enhancement to Accommodate Improved Efficiency and Decreased Resource Utilization in Complex Minimally Invasive Surgical Procedures. IV International Symposium Medicine Meets Virtual Reality, San Diego, USA, Jan. 17-20th, 1996

Harding, R. Gearing up for a new era in surgery: Robotic assistance. Same-Day Surgery, 18, 86, 1994

Kavoussi, L., Moore, R., Adams, J., Partin, A. Comparison of Robotic Versus Human Laparoscopic Camera Control. J. Urol., 154, 2134, 1995

Mettler, L., Ibrahim, M. and Jonat, W. One year of experience working with the aid of a robotic assistant (the voice-controlled optic holder AESOP*) in gynaecological endoscopic surgery. Hum. Reprod., vol. 13, no. 10: 2748-2750, 1998

Reich, H., De Caprio, McGlynn, J. F. Laparoscopic hysterectomy. J. Gynecol. Surg. 5: 213-216, 1989

Semm, K. Hysterektomie per laparotomiam oder per pelviscopiam. Geburtsh. u. Frauenheilk. 51: 996-1003, 1991