In today’s society the market for new inventions is based primarily on the demand for the product verses the cost to produce and uses the product. Robotic surgical equipment is costly to purchase, plus the cost of cross training the surgeons on the machine. This is one of the reasons robotics have been slow to enter the medical field and once created slow to be utilized over the current standard medical procedures. The most well-known
surgical medical robots are Da Vinci and Zeus. Less well known are the catheter based robots; Sensei X systems, Magellan systems, and NIOBE magnetic navigation systems. Minimally Invasion
The new robotic surgeries are minimally invasive, which increase the appeal over the traditional methods. “The pain, discomfort, and disability, or other morbidity as a result of surgery is more frequently due to trauma involved in gaining access to the area to perform the intended procedure rather than from the procedure itself” (Mack, 2001, Para. 2). The uses of robotics and the minimally invasive procedures have resulted in “superior outcomes manifested as improved survival, fewer complications, and quicker return to functional health and productive life” (Mack, 2001, Para. 2). The minimally invasive surgeries are only made possible by the advancements in imaging technology. For the first time, the surgeon did not look directly at the target structure but viewed digitally enhanced images that provided a better visualization because of the magnification and illumination. “These technologies facilitated this shift: (1) development of the charge coupling device (CCD) chip that allowed high resolution video images to be transmitted through an optical scope to the surgeon, (2) high intensity xenon and halogen light sources that improved visualization of the surgical field, and (3) improved hand instrumentation designed for endoscopic approaches” (Mack, 2001, Para. 5). The new imaging technology used in medical robots create a high resolution image with perfect 20/20 vision and the added benefit of magnification options for even better visual image of the surgical area. Zeus System
The multiple arm style robots that perform many different kinds of surgery are the Zeus system and the Da Vinci system. The Zeus system is composed of a surgeon control console and 3 table-mounted robotic arms. The right and left robotic arms replicate the arms of the surgeon, and the third arm is an AESOP voice-controlled robotic endoscope for visualization. In the Zeus system, the surgeon is seated comfortably upright with the video monitor and instrument handles positioned ergonomically to maximize dexterity and allow complete visualization of the OR environment. The system uses both straight shafted endoscopic instruments similar to conventional endoscopic
instruments and jointed instruments with articulating end-effectors and 7 degrees of freedom. (Lanfranco, Castellanos, Desai, & Meyers, 2004, Para. 13)
Image of the Zeus System
(Lanfranco, et al., 2004) The Zeus Robotic Surgical System is produced by Computer Motion, a company that is located in Santa Barbara California. It was first used in heart surgery at the University of Pittsburgh during a beating heart cardiac bypass. “A 63-year-old male patient underwent multi-vessel off-pump coronary artery bypass graft (CABG) surgery at the University of Pittsburgh Medical Center’s Presbyterian Hospital in early April. Surgeons used the three-armed robot during the most important part of the operation, when the artery being used as the bypass graft is connected to the heart’s main coronary artery” (“Product Brief: Zeus”, 2008, Para. 2). Image of the Da Vinci System
(Lanfranco, et al., 2004) Da Vinci Surgical System
In the da Vinci system, which evolved from the telepresence machines developed for NASA and the US Army, there are essentially 3 components: a vision cart that holds a dual light source and dual 3-chip cameras, a master console where the operating surgeon sits, and a moveable cart, where 2 instrument arms and the camera arm are mounted.1 The camera arm contains dual cameras and the image generated is 3-dimensional. The master console consists of an image processing computer that generates a true 3-dimensional image with depth of field; the view port where the surgeon views the image; foot pedals to control electro cautery, camera focus, instrument/camera arm clutches, and master control grips that drive the servant robotic arms at the patient’s side.6 The instruments are cable driven and provide 7 degrees of freedom. This system displays its 3-dimensional image above the hands of the surgeon so that it gives the surgeon the illusion that the tips of the instruments are an extension of the control grips, thus giving the impression of being at the surgical site. (Lanfranco, et al., 2004, Para. 12) Some of the surgeries that Zeus and Da Vinci are capable of performing
are; Transoral Robotic surgery (TORS), Bladder Cancer, Colorectal Cancer, Coronary Artery Disease, Endometriosis, Gynecologic Cancer, Heavy Uterine Bleeding, Kidney Disorder, Kidney Cancer, Mitral Valve Prolapse, Obesity, Prostate Cancer, Throat Cancer, Uterine Fibroids, and Uterine Prolapse. The numbers of procedures these systems can perform are growing as the medical community because more familiar with these systems. Catheter-Based Robotic Intervention
Another type of robotic surgery is the catheter-based robotic intervention. There are two different types of catheter-based robotic intervention technologies in uses currently, electromechanically based system and magnetically controlled system. I found two electromechanically catheter-based systems, the Sensei X system and the Magellan system. The Sensei X Robotic Navigation System was developed by Hansen Medical Inc. in Mountain View California and designed for electrophysiology interventions. The Sensei X system consists of a surgeon’s workstation, a remote catheter manipulator and a steerable guide catheter. The workstation has a visualization module, which incorporates real-time imaging and 3D electro anatomical mapping and a manually controlled input device for controlling catheter motion. The remote slave catheter robot is mounted on the operating table. The Artisan Extend[trademark] Control Catheter (Hansen Medical, Mountain View, CA, USA) consists of an articulating inner guide 10.5 cm in length, a steerable multidirectional inner guide (11.5 F outer diameter), and steerable unidirectional outer guide sheath (14 F outer diameter). The system accommodates catheters that are 8 F or smaller in diameter and have a minimum usable length of 115 cm. The system may be delivered over an independent guide wire, but does not depend on that wire to maneuver. The system provides 6 degrees of freedom and allows transmission of the surgeon’s movements to the catheter tip, while the outer guide provides stability. (Del Nido, DuPont, & Vasilyev, 2012, Para. 4) The Magellan Robotic System
The Magellan Robotic system is used for peripheral vascular interventions. The Magellan System works with the novel NorthStar [trademark] catheter (Hansen Medical, Inc.), which is designed to ensure simultaneous distal tip control of a catheter and a sheath, enabling more precise device deployment. The tip of the sheath is articulated up to 90° in any direction, while the tip of the leader is articulated in up to 180° in any direction. The system may also accommodate devices 6 F or smaller. (Del Nido, et al., 2012, Para. 4) The magnetically controlled system I found is called the NIOBE Magnetic Navigation System. The NIOBE® Magnetic Navigation System (Stereotaxis, St Louis, MO, USA) is operated by a magnetic field created by two computer-controlled 0.08 T permanent magnets. The magnets are mounted on articulating arms that are enclosed within a stationary housing, with one magnet on either side of the patient table. By changing the positions of these magnets with respect to the patient, deflection of the magnetic tip of the catheter can be precisely controlled. This requires the use of proprietary magnetic intravascular guide wires (TITAN® and Pegasus [trademark] [Stereotaxis]), which are advanced manually. The system accommodates diagnostic and ablation catheters up to 8 F in diameter, with up to 120° bend radius. (Del Nido, et al., 2012, Para. 5) Like other robotic surgeries, catheter-based robotic intervention has its advantage and its disadvantages. Some of the advantages demonstrated in different studies of the catheter-based robotic interventions are; “reduction in procedure times, increased precision in targeting and increased catheter tip stability in comparison with standard manual navigation. In addition, surgeon comfort and ergonomics were significantly increased while at the same time fluoroscopy exposure for the surgeon was reduced” (Del Nido, et al., 2012, Para. 7). The disadvantages of catheter-based robotic intervention, is due to the limitation of the design of the current system. These limitations include “ability for significant force application, especially in a lateral direction from the axis of the catheter and stable position control that is sufficient for tissue manipulation” (Del Nido, et al., 2012, Para. 8). The History of Surgical Robots
The idea for robotic surgery or robotic assisted surgery actually dates back to the 19th century with the concept of surgery through a scope but the technology to make this idea a reality was not available until the mid to late 1980’s. “Minimally invasive surgery began in 1987 with the first laparoscopic cholecystectomy. Since then, the list of procedures performed laparoscopically has grown at a pace consistent with improvements in technology and the technical skill of surgeons.” (Lanfranco, et al., 2004, para.5) The technology that allowed laparoscopically surgery to become a reality is: (1) The development of the charge coupling device (CCD) chip that allowed high resolution video images to be transmitted through an optical scope to the surgeon, (2) High intensity xenon and halogen light sources that improved visualization of the surgical field, and (3) Improved hand instrumentation designed for endoscopic approaches. For the first time, the surgeon did not look directly at the target structure but viewed digitally enhanced images that provided a better visualization because of the magnification and illumination. (Mack, 2001, Para. 5) Laparoscopic surgery was the beginning of minimally invasive surgery, with the advantages of smaller incision, less chance of infection, and the reduction of the amount of time the patient needed to recover in the hospital. However Laparoscopic surgery has several limitations, Some of the more prominent limitations involve the technical and mechanical nature of the equipment. Inherent in current laparoscopic equipment is a loss of haptic feedback (force and tactile), natural hand-eye coordination, and dexterity. Moving the laparoscopic instruments while watching a 2-dimensional video monitor is somewhat counterintuitive. One must move the instrument in the opposite direction from the desired target on the monitor to interact with the site of interest. Hand-eye coordination is therefore compromised. Some refer to this as the fulcrum effect. Current instruments have restricted degrees of motion; most have 4 degrees of motion, whereas the human wrist and hand have 7 degrees of motion. (Lanfranco, et al., 2004, para.5) The desire to overcome the limitations of the Laparoscope is one the reasons the current surgical robots were developed. Evolution
The evolution of robotic surgery starts with the Puma 560, PROBOT, and ROBODOC. These early robots were designed for specific types of surgery. They did eventually lead to the more versatile robots of Automated Endoscopic System for Optimal Positioning or AESOP, Zeus, and Da Vinci. The first robot to be used in surgery was the Puma 560. It was in 1985 that the Puma 560 preformed its first neurosurgical biopsies. Within a few years the Puma 560 was converted into the PROBOT, which was designed to perform
transurethral resection of the prostate. At the same time Integrated Surgical Supplies Ltd developed the ROBODOC. The ROBODOC was the first robot to be FDA approved. “The first clinically successful robot, the Robodoc, was introduced for use in total hip replacement. The initial goal was to replace the camera holder with surgeon-controlled robot.”(Ballantyne, 2002, p. 1390) “This robotic arm was remotely controlled with a finger ring that was clipped to one of the surgeon’s instruments.” (Ballantyne, 2002, p. 1390) Also in the mid-to-late 1980s a group of researchers at the National Air and Space Administration (NASA) Ames Research Center working on virtual reality became interested in using this information to develop telepresence surgery. This concept of telesurgery became one of the main driving forces behind the development of surgical robots. In the early 1990s, several of the scientists from the NASA-Ames team joined the Stanford Research Institute (SRI). Working with SRI’s other robotocists and virtual reality experts, these scientists developed a dexterous telemanipulator for hand surgery. One of their main design goals was to give the surgeon the sense of operating directly on the patient rather than from across the room.
While these robots were being developed, general surgeons and endoscopists joined the development team and realized the potential these systems had in ameliorating the limitations of conventional laparoscopic surgery. The US Army noticed the work of SRI, and it became interested in the possibility of decreasing wartime mortality by “bringing the surgeon to the wounded soldier—through telepresence.” With funding from the US Army, a system was devised whereby a wounded soldier could be loaded into a vehicle with robotic surgical equipment and be operated on remotely by a surgeon at a nearby Mobile Advanced Surgical Hospital (MASH). This system, it was hoped, would decrease wartime mortality by preventing wounded soldiers from exsanguinating before they reached the hospital. (Lanfranco, et al., 2004, Para. 7 & 8) As of yet the robotic systems have not been implemented to care for wound soldiers on the battlefield. Several of the Army employees that were on the project left to start a civilian commercial company of Computer Motion Incorporated. There companies first robot was AESOP, a voice controlled robotic arm that controlled the endoscopic camera. “In 1994, the FDA approved AESOP for clinical use as a robotic camera holder.” (Ballantyne, 2002, p. 1390) Around the time AESOP was launched, the designers of the ROBODOC consulted with the Stanford Research Institute (SRI) to redesign there system. “This system underwent extensive redesign and was reintroduced as the Da Vinci surgical system. Within a year, Computer Motion put the Zeus system into production.” (Lanfranco, et al., 2004, Para. 9)
Political and Legal Influences
Questions are revolving everywhere around the world about whether or not robotic surgeries should be performed on patients. Even though these concerns seem to take a toll on the procedure, we know as we said earlier that there is a major demand with the technology. The use of robotics has affected society in a major way. With that being said, the relationship between the technology and society has been applied with developments being made to enable medical professionals and patients to improve their way of living. Not only does robots affect science fiction, but real-life as well. We are experiencing a social revolution, and robots have never been easy. Instead of manually working, robotics create their own knowledge to give patients the necessities they need. International Use
Robotic surgeries are not only performed in the United States, but also internationally as well. In fact, the first robotic surgery was accomplished by Canadian physicians. There is no mystery here, since for any type of painful procedure, they are going to need anesthetic being performed. “As with any patient having any surgical procedure, the selected anesthetics should be catered around the patient, the patient’s history, and their accompanying co-morbidities” (Woolacott, 2010). Never use nitrous oxide with the laparoscopic procedures for many reasons. Costs
Robotic surgery has brought much excitement to the medical field, but comes with a steep price. Researchers have found that the number of robotic surgeries performed in the United States has increased. “Each system ranges in price from $1 million to $2.5 million, and the use of robotic surgery increases the cost of procedures anywhere from $3,200 to $8,000. “There is a major difference in operative costs between open, laparoscopic, and robotic
surgery resulting from added expense of specialized equipment” (Darwish, 2011). The Da Vinci robot is very costly in terms of services. It requires a yearly service contract of $200, which includes the limitation of the applications. With the robotic surgeries being performed every day, the fixed costs depend mainly upon the number of cases being operated over the life span of the robotic system. “If utilized for 300 cases per year and amortized over 7 years, it adds more than $1326 per case, but if less patients are operated yearly the costs of robotic assisted surgery increase even more” (Darwish, 2011). Overall, robotic surgeries increases the annual cost of health care by $2.5 billion” (Lipschitz, 2010). Training
For the surgeries to be successful, employees need to be trained in order to perform the best surgery for the patient. “Surgeons in training have always had to gain operative experience through supervised trial and error on real patients. This approach makes surgical training completely dependent on the actual case load, prolongs surgical training, and compromises patients’ safety” (Morris, 2005). There will be images of simulations that will allow the surgeons to practice procedures on three-dimensional figure of the anatomy of the actual patient who they plan to operate every day. With these simulations, the employees (whom are trainees) would be guided through telementoring. “Telepresence surgery has been also successfully used in teaching surgical skills to third year medical students” (Morris, 2005). Selection
The assessment of choosing a patient selection is difficult. Why is that? Well, you have to have the surgical skills and the uses of robotic technology. “Careful preoperative assessment of patient risk is critical for preventing perioperative complications” (mass.gov). Both the patient and the surgery are vital factors to be considered. Also, “there has to be a special committee to monitor the practices and outcomes, as noted for credentialing and may be useful to develop the robotic surgery-specific preoperative assessment guidelines and protocols” (mass.gov). Along with all these guidelines, always pay special attention to the influences of direct to patient marketing and other factors that may introduce different dynamics into the patient selection process. With the risks that can take effect on
any patient, the surgeon should explain in context of the patient’s clinical condition. If not, then how are they going to perform the specific procedures? “Patients should be advised on the experience of the surgeon in performing the recommended robotic procedure” (mass.gov). There is also websites that can be accessed to view the completeness of information regarding both the risks and benefits of robotic surgery. Placement
During a laparoscopic procedure in robotic surgery, there is a way where a patient needs to be placed properly. The patient will need to be under anesthesia, the needed lines would be in place, and now the robotic surgeons would be ready to go. It is definitely vital to have all the employees in the operating room take initiative in properly positioning any patient for the surgical routine. “However, with robotic assisted procedures, there a few nuances. Also, a surgeon may have a particular positioning technique or strategy which is fine as long as it’s safe for the patient” (Woollacott, 2010). Psychological Considerations and Sociological Effects
The introduction of medical and surgical robot technologies is rapidly changing the practice of medicine. The aim is to analyze how technological, social and psychological factors mutually affect person-friendly robot interaction, including the major determinants of utility, usability, and acceptability. The appropriate allocation of tasks and capabilities between the robot, the surgeon, assistant surgeons and other members in the operation team proves to be a dilemma. When robots coexisting with humans are designed, it is important to evaluate psychological influence of shape, size and motion of the robots on the humans. Both patients and doctors feel uncomfortable working next to medical robots which tower above the surgeon at over 7 feet and weigh in at several tens of kilograms. There is some logic behind that, however. A larger robot can usually exert more force than a smaller one, resulting in an increased amount of damage in case of a fault. Robotic surgery exists because of a societal need. It has stemmed from an inherent physical need for surgery and has evolved to become what it has by means of improving previous processes. Robotic surgery strengthens and enhances the surgical procedure, by filling in the gap that surgeons’ own physical limitations present. (Retrieved from http://allaboutroboticsurgery.com/zeusrobot.html) Evaluation is an integral part of any surgical operation. In a robotic one, it is even more so since the surgeon did not have an opportunity to check everything before proceeding with the subsequent steps. If it is found that something is not completely satisfactory, then the surgeon has the option to either repeat the whole operation or to carry out a manual procedure to complete the work. It has been shown that, in the operations conducted robotically, robots can produce superior results to human surgeons. For example, the milling of a socket for an artificial hip replacement has been performed with greater accuracy (in terms of ‘fit’ and ‘contact’ of the prosthesis) than a human surgeon can perform. In particular, one of the main criteria for success in this type of operation is the percentage of the prosthesis that is in contact with the bone of the socket. Robotic surgeons have managed up to 83% as compared to around 30% for humans.
This, on the surface, dramatic improvement is tempered by the fact that a different approach (not using robotics) has also yielded 83% contact. This approach uses humans to mill the socket and then custom-produces the artificial hip to fit the shape of the socket. Thus, the robotic solution must be able to show some other improvement (e.g. cost- or time-wise) if it is to replace the human surgeon altogether. Laparoscope robots are generally evaluated by measuring work efficiency, precision and error rates, and by using interviews and questionnaires to gather the opinions of surgeons. In cases where the interaction between laparoscope robots and the surgeons operating them resulted in bad feelings, the result was that this drawback worsened the overall performance of the system even if the robot performed excellently in all other aspects. It is therefore necessary to evaluate stress by using interviews, questionnaires and the like. However, interviews and questionnaires produce subjective results that tend to be rather vague, and it is also possible that the results are affected by the human relationship between the examiner and examinee. For the objective measurement of stress, there is growing interest in methods that use biological stress responses. The concept of biological stress responses was defined by the physiologist Hans Selye as “the nonspecific response of the body to any demand upon it” (Selye, 1936; Selye, 1974). Since stress appears to originate from very complex mechanisms, not only do different people respond differently to stimuli, but even the same person can exhibit a range of different responses to the depending on whether the stress is comfortable or uncomfortable, psychological or physical, and so on. (Retrieved from Selye, H.(1974) Stress without Distress, Lippincott Williams & Wilkins).
Larger size robots used in surgery is a disadvantage in crowded operating rooms. Larger operating rooms and machines, which are made smaller, can possibly remedy this situation, though this also poses an issue of cost. Sociological Effects
The major social issues that is raised with this technology is the fact that it would be expensive to construct and use making only necessary to the rich. The other main issue is how robotics would intermingle with the surgeons. This could result into different health complications and risks such as reactions to medicines, difficulties in breathing, bleeding and infection. Even though robotic surgery could have fewer risks, the complications, especially infection and bleeding is never completely eliminated. In some cases, social matters associated to developed surgical technology, like implementation of undocumented technology or itinerant surgery, also arise. With every new dilemma, the grounds have continued to emerge, though the resolutions have become more complicated. We are experiencing a social revolution (May, 2002). We have shifted and continue to shift from manual work to ‘knowledge’ work and our society base has moved from that of goods to knowledge (Drucker in May, 2002, p. 5). Robots were once only science fiction but have now become a reality. This revolution is occurring in the field of surgery, using robotics to make ‘knowledge’ work, in place of ‘manual’ work. Future Technology
There are several steps that must be taken in order to further the use and development of robots in surgery (and in medicine in general). These are: * the development, and international adoption, of safety standards * the aim of task-specific, as opposed to general-purpose, robots * the education of the medical community in the acceptance and integration of robots The economic and social advantages to be gained from the mass-use of
robotics in medicine (and particularly surgery), as already expounded, are enormous. If all of the above steps are taken, then the full potential of robotics can be exploited in the medical sector, as it has been in industrial applications, for the improved welfare of society everywhere. In the future, maybe sooner than we think robots may help doctors improve their ability to diagnose and treat disease. Whether a doctor is at a patient’s bedside or is miles away, the doctor may have a better sense of “feel” inside the body. Operating rooms of the future may look a little different, because a robot might be doing some of the work. The economic and social advantages to be gained from the mass-use of robotics in medicine (and particularly surgery), as already expounded, are enormous. The technology in its cultural context, media influence
Technology has constantly improved in every aspect of the modern life. The world would never be the same without such kind of improvements. The society revolves around technology and people depend on it for almost everything from simple mobile phones that help in observance of daily schedule to accuracy in operating rooms. It is the media’s influence that assists in pushing technology across different cultures. The coverage of the major benefits of the technology internationally helps in its quick adoption. The robotic surgery technology has numerous benefits that could change the future of therapeutic treatment. Even though the fresh installments of the technology will have both merits and demerits, currently, robotic surgery will transform the state of medical care and will assist thousands of people. It will be readily adopted due to extensive media coverage. Robotic surgery technology is used in a variety of different medical contexts, with different minimally invasive surgeries being performed in the different disciplines such a gynecology, urology and cardiology etc. Similar technology is used in defusing bombs – this technology uses the similar idea of robotics with telesensors and telepresence to operate a system remotely. Most robots are equipped with arms and degrees of movement and agility are sent into the field and controlled by consoles, which are at a distance, demonstrating a collaboratory with humans and machines interacting together. Similarly, this collaborator and robotic technology is used within the context of space exploration. Exploratory devices are sent into space and
controlled from space vehicles and from earth. Surgeons are trained to use robotic technologies, demonstrating the opposite influence, that of technology on society. Robotic surgery also has the positive influence on society with its positive surgical outcomes as results of using robotic technology in procedures. Our society revolves around technology. We depend on the intelligence of technology for everything that we do, from our telephones keeping track of our daily schedule to the preciseness of robotics in the operating room. The media’s influence is what aids in the push for technology across most cultures. This new medical assistant has become popular across almost every nation. Not only is robotic surgery accepted, the idea of robots started long before Leonardo Da Vinci. There is general concern about the safety of the robot, and the competence of it working next to humans. Since complete safety is unattainable, however, the question arises: When is a medical robot safe enough? This greatly depends on the application. If it is to perform an ordinary operation, the robot’s abilities must match if not surpass those of a surgeon. If it is to perform a life-saving operation that would be otherwise impossible, it is plausible that the safety requirements can be relaxed, since the patient would die anyway if the operation is not performed. This solves, nevertheless, only part of the problem. Life-saving operations are invariably complicated ones, resulting in the need for a robot with sophisticated capabilities, which, as mentioned earlier, results in a greater probability of error. Cultural Contents
The idea of “Working smart, not hard”, has gone back a long way and continues to be a driving force today. Leonardo Da Vinci came up with the idea of using robots to aid in the intricate procedures placed in the hands of a surgeon. Da Vinci invented the first robot in the operating room to reduce the risks associated with surgery and to minimize the cosmetic aftermath of having surgery. A person’s physical image means a lot in today’s society, therefore the idea of this surgical system caught the eyes of the media and the media has been able to “spread the word”. The Hamilton Spectator newspaper published an article regarding a family who gave St. Joseph Hospital $5 million to purchase Da Vinci’s surgical system for patients to have the option of using for their procedures. The media
actual gives its readers an idea of how much a procedure using the Robotic System could cost them. . One of the largest multispecialty robotic surgery centers is in New York. They perform robotic-assisted urologic, gynecologic, mitral valve and general cardiothoracic surgery. The superior maneuverability of a robotic tool is ideally suited for delicate cutting and stitching required in this surgery, while the minimally-invasive nature of the procedure is less traumatic, and helps preserve kidney function and results in faster recovery time.
The future applications of robots in medicine will be further expounded, and the field of robotic (and robotically assisted) surgery will be concentrated upon, along with such issues as safety and implementation. Maybe sooner than we think robots may help doctors improve their ability to diagnose and treat disease. Whether a doctor is at a patient’s bedside or is miles away, the doctor may have a better sense of “feel” inside the body. Operating rooms of the future may look a little different, because a robot might be doing some of the work. The media influences on the technological cultural context of remote robotic surgery have been positive. Media has reported on the case-by-case study of how robotic surgery may help alleviate over booked operating rooms. Conclusion
Robots play important roles in our lives and are no longer bound by the realms of science fiction. Surgical robotics play an integral part in medicine, ensuring the lives and quality of life is improved through this revolutionary technology. This technology will continue to develop and improve as part of the ongoing process of social informatics. The interplay of social, technological and communicative technologies will ensure that this technology develops to serve society in a useful and dynamic manner. Environmental Implications
The never ending advancement of technology all around us, especially in robotic surgery has prompted change in surgical procedures and may one day become the standard for surgical care. The potential of robotic surgery is limitless. This potential and the desire for better healthcare are driving
the paradigm shift. This change directly affects the environment in which it is being used. Clinical
With the introduction of robotic surgery, the clinical environment must change and adapt to accommodate these systems. The surgical environment must be sterile at all times and robotic surgery fits this need. As well as being sterile, the robotic system will add to the amount of surgical equipment and personnel within the surgical suite. This surgical suite environment may include the surgeon, OR staff, surgical/OR equipment, robotic surgical system, and a manufacturer representative. Langdon Winner “has explored further the idea that the entire ensemble of modern technological systems, including the background conditions required to keep them operating, tends to promote centrally coordinated, technocratic social administration” (Winston & Edelbach, 2012). As a consequence, the surgical procedure’s success is limited to how efficient the surgical team works together in this new environment. As the surgical team’s efficiency in the procedures and training allows the robotic system to become part of the environment and requires less change as time goes by. Human Anatomical
As robotic surgical systems become used more during surgical procedures, society will automatically assume that using robots to perform surgery is superior to all other forms of surgery with better results. People not requiring a surgical procedure will develop the perception that robotic surgery is a safer, more accurate alternative in performing difficult surgical procedures on the human body, especially with approval by the U.S. Food and Drug Administration. Since the robot does come into direct contact with the patient, safety measures have to be put into place to ensure that the negative effects of this interaction between the robot and the human anatomical environment are minimized. (Barnett, Judd, Wu, Scales, Myers & Havrilesky, 2010) There must be established fail safes as well as properly trained operating room staff capable of recognizing when an event is unrecoverable and becomes necessary to convert the surgery to either laparoscopic or open procedure. Surgeons or operating room personnel could easily blame human error as a technical error caused by the robotic system itself. Standard operating procedure criteria must be followed and
documented during robotic surgeries. This documentation allows for lessons learned and improvements can be made with staff and the robotic system. Patient
The patient is surrounded by a large, intimidating piece of robotic equipment during surgery as well as the Patient-side Cart. “The Patient-side Cart contains the various “arms” of the robot with each extension containing a separate instrument to be used during the surgery” (Intuitive Surgical, 2013). Along with the robotic system, the patient is surrounded by operating room staff as in a traditional surgical procedure. The surgeon is the only person not with the patient; instead the surgeon is off to the side comfortably seated in the Surgeon Console. The U.S. Robotics report states that “the advances in robotic surgery have the potential for leading to new treatments to treat a host of health issues and improve the standard of care, how care is accessed, and positive outcomes” (Christensen, 2013). Surgical procedures that require micro-suturing or reconstruction are proving robotic surgery to be a great alternative to traditional surgical methods. However, pediatric and small space surgeries are difficult due to the relative size of the robotic system to the pediatric patient/small space. “Quality care, less scaring and pain, minimal invasiveness, and faster healing time are all advantages that a patient is looking to robotic surgery to address” (Christensen, 2013). Provider
The surgeon sits at the Surgeon Console in an ergonomically correct position that lessens the effects of fatigue that are normally experienced during traditional surgery lengths. Superior 3D visualization provides the surgeon with the ability to clearly see the surgical field and properly use the hand controls to maneuver the surgical instruments even in the smallest of incisions. (Intuitive Surgical, 2013) “The surgeon can cut, cauterize and suture with accuracy equal to or better than that previously available only during invasive open surgery.” (Christensen, 2013) This is accomplished by the Endowrist which allows for greater dexterity and rotation of the surgeon than allowed by the confines of the physical abilities of the surgeon. Research shows that the noise level in the surgical room does negatively impact the performance of the surgeon while operating using the robotic
system. (Siu, Suh, Mukherjee, Oleynikov & Stergiou, 2009) The robotic system adds more distracting noise to an already noisy operating room that can distract the surgeon. In order to combat the distracting noise level, surgeons should gain as much experience and time as possible with robotic surgery systems to get used to the increased noise levels. The U.S. Robotics report (Christensen, 2013) suggests that robotics compensate and alleviate for human physical limitations when performing technically difficult surgeries while still allowing the human to have complete control over the process. The surgeon still applies their vast knowledge and experienced skill into controlling the robotic system, all the while ensuring the robotic system remains a surgical tool and does not become a replacement for the surgeon. Accommodations
With the additional space needed to accommodate the robotic surgical system, operating rooms/surgical suites must be larger than established norms. Sclove proposes that “In order to function, technologies require various environmental and organizational background conditions.” (Winston & Edelbach, 2012) Hospitals that are in the market to purchase these robotic systems must complete some renovations within their operating rooms/surgical suites in order to accommodate the space taken up by them and to allow the staff to move around efficiently. The need for personnel that are specialized in the operating room/surgical suite with robotic surgery systems has increased. These individuals must understand what the requirements are for setting up the room pre-operation, equipment sterilization, system maintenance, changing out instruments, and cleaning up post operatively. Also, these individuals must know what to do in the case of a system failure. Staff Training
Currently there are no standard training requirements however; all staff involved in the process of robotically assisted surgery should have at least a minimum of training from the manufacturer. (Herron & Marohn, 2007) Until the surgeon and staff are confident in their abilities in the operation of the robotic system, a representative from the manufacturer should be present during the initial surgeries performed. Operating room
staff has hindered access to the patient due to the sheer size of the robotic system’s components. This will require the operating room staff to conduct regular training in order to efficiently move around the added robotic equipment and reduce surgical times with better knowledge and experience. It is estimated that it takes a surgeon and surgical team about 12-15 robotically assisted surgeries until everyone starts to feel more comfortable. As a result of this learning curve, this translates into increased time spent doing the surgical procedure as well as the staff requiring more time to set up and close down the operating room. (Herron & Marohn, 2007) Moral and Ethical Implications
The moral implications pertaining to robotic surgery have many patients worried about what will happen to them during a robotic surgery. Extensive research has been performed on robotic systems and as with every surgery; the surgeon must disclose every aspect of the surgery to the patient. This allows the surgeon to address any patient concerns. The research on robotic surgeries has shown that there is a reduction in the “invasiveness of interventions, while ensuring high levels of accuracy.” (Datteri & Tamburrini) The primary purpose of using robotic surgery was to reduce the invasiveness of surgeries and lessen physical and psychological discomfort of the patients. Patient Reactions
The moral implications are creating issues for many patients with the use of robotic surgery systems. Mainly because patients do not know enough about why this should be an option for them. The fear of the unknown causes negative reactions to a surgery that can actually benefit them. Patients are concerned with their physicians, not providing adequate information and full disclosure of what can or will happen with the surgery. Just like many surgeries, there may or may not be complications or concerns. Robotic surgeries have the same procedures and policies that need to be followed. Robotic surgeries have helped many surgeons from becoming fatigued, reduces their numerous tasks that are required before the surgery, therefore, reducing human errors, complications and side effects. Health Concerns
The health concerns that patients believe can occur from robotic surgery are less likely to happen than any other surgery. Trident Health states that there is less scarring, shorter hospital time, reduced blood loss, faster recovery, reduced trauma to the body, less post-operative pain and discomfort, and smaller risk of infection (Trident Health, 2013). As with any type of surgical procedure, health risks are inherent however; robotic surgery reduces this risk considerably. Surgeons must be trained on the robotic system(s) so they can develop their skill/technique for performing any surgery assisted with a robotic system. Patient safety and health is a priority at all times for the surgeon and staff. Just as in a traditional surgical procedure, the unimaginable can happen however it is less likely to happen if undergoing a robotic surgery. Surgeon Self-Improvement
Computer-enhanced technology combined with the surgeon’s talent means that “surgeons are able to perform delicate and complex operations through a few tiny incisions with increased vision, precision, dexterity and control.” (Intuitive Surgical, 2013) Surgeons must remain up-to-date on evolving robotic surgical system technologies in order to improve their skills. Many surgeons need to have “the courage to try out innovations” (Ellis, Cavanagh & Redman, 2009), which means they need to be willing to be unconventional in the absence of clinical trials before trying the robotic surgeries. Ethical
New robotic technologies are causing concerns for patient safety which in turn opens the door for ethical dilemmas to present themselves. The focus has shifted from the individual patient and the conduct of medical practice to the impact that robotic technologies have changed how the world sees surgery. Patients are concerned that this new technology has ethical repercussions with the continual development of this technology. Complex litigation is a growing concern for most organizations that use robotic surgery. “In case of an undesirable outcome, in addition to physician and hospital, the manufacturer of the robotic system may be sued” (Mavroforou, Michalodimitrakis, Hatzitheofilou & Giannoukas, 2010). Equipment safety and reliability, providing adequate information, and confidentiality of
patients are raising ethical dilemmas with robotic surgery. These dilemmas must be of the highest priority. Global Health
Robotic surgery is not available in all of the world’s countries. Some countries have tried with poor equipment which led to non-effective results. Globally, religion is a growing concern with the use of robotic systems to perform surgeries. Religious beliefs in many countries prohibit surgical procedures, traditional or robotic. Global health has become a growing concern these days. Robotic surgical system technologies are not fully understood how they can help people in every country. Training Concerns
Future surgeons will still be trained in traditional methods along with new robotic surgical system technologies. The Da Vinci technology is made accessible to everyone who needs it with detailed instructions as to how it needs to be taught. “The da Vinci Surgery Training Pathway is divided into three distinct phases, with reinforcing activities and supporting tools for both surgeons and operating room staff available every step of the way.” (Intuitive Surgical, 2013) Patient Concerns
Patient-surgeon contact is the primary concern with most patients when robotic surgery is an option. A patient must be able to feel as though their surgeon is concerned with their well-being. The surgeon must understand and address patient fears, concerns, and answer any questions a patient may have. The robotic system detaches the surgeon from the patient which in return could make a patient feel as though their level of care is less and unimportant. Another concern is that the surgeon may not be able to perform the surgery as they would if they were doing it themselves. A surgeon may not properly feel the organ(s) by using robotic technologies and thus putting too much pressure on delicate organs. Practice of Medicine Concerns
A growing concern is patient confidentiality and third party entities invading the privacy of patients. Another concern many patients have is the Health Insurance Portability and Accountability Act (HIPAA) law being enforced. Distributive justice, physical and mental integrity, and
personality change are just a few of the concerns with the surgeons not doing the surgery themselves.
Anthony R. Lanfranco. “Robotic Surgery”, Annals of Surgery, 01/2004 http://cdn.intechweb.org/pdfs/6446.pdf
Barnett, J. C., Judd, J. P., Wu, J. M., Scales, C. D., Myers, E. R., & Havrilesky, L. J. (2010). Cost comparison among robotic, laparoscopic, and open hysterectomy for endometrial cancer. Obstetrics & Gynecology, 116(3), 685-693. doi: 10.1097/AOG.0b013e3181ee6e4d Christensen, H. (2013, March 20). A roadmap for u.s. robotics from internet to robotics. Retrieved from http://robotics-vo.us/sites/default/files/2013 Robotics Roadmap-rs.pdf Datteri, E., & Tamburrini, G. (n.d.). Ethical reflections on health care. Retrieved from http://people.na.infn.it/~tamburrini/pub/Datteri_Tamburrini_Ethics and Robotics.pdf Ellis, D., Cavanagh, S., & Redman, B. (2009, June 22). Robot ethics. Retrieved from http://www.hhnmag.com/hhnmag/jsp/articledisplay.jsp?dcrpath=HHNMAG/Article/data/06JUN2009/090622HHN_Online_Ellis&domain=HHNMAG Herron, D. M., & Marohn, M. (2007). A consensus document on robotic surgery. Society of American Gastrointestinal and Endoscopic Surgeons, Retrieved from http://www.sages.org/publications/guidelines/consensus-document-robotic-surgery/ Surgery, 147(1), 107-113. doi: 10.1016/j.surg.2009.08.010 Intuitive Surgical. (2013). The da vinci surgical system. Retrieved from http://www.intuitivesurgical.com/ Lanfranco, A. & Castellanos, A. E. & Desai, J. P. & Meyers, W. C., 2004, ‘Robotic surgery: a current perspective’, Annals of Surgery, Vol. 239, No.1, Pp. 14-21, viewed 1 Nov 2011 <https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1356187/pdf/20040100s00003p14.pdf>.
Mack, Micheal J. MD. (February 7, 2001). Minimally Invasive and Robotic Surgery.
JAMA. 2001; 285(5):568-572. doi:10.1001/jama.285.5.568.
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