ROBOTICAND

TELESURGERYDr. Fathi Neana, MD

Chief of OrthopaedicsDr. Fakhry & Dr. A. Al-Garzaie Hospital

Saudi ArabiaJanuary,10 - 2018

We live in an age of a new unpreceded

wonders

The wonders of the world are not seven any more

The inanimate talk to us

We are flying in the air

More than 65,000-Ton can float over the water in an iron vessel

The Robotic Doctor is already a reality

عصر العجائب وظهور المخترعات الحديثة المتتابعة

والمؤثرة في حياة الناس

:قال رسول صلى هللا عليه وسلم

( .ال تقوم الساعة حتى تروا أمورا عظاما لم تكونوا ترونها وال تحدثون بها أنفسكم )

فإذا رأيتم ذلك ستـــرون قبل أن تقوم الساعة أشياء تستنكرونها عظاما تقولون هل كنا حدثنا بهذا ) (.فاذكروا هللا تعالى وأعلموا أنها أوائل الساعة

ليه وأنه يحصر المؤمنين في بيت المقدس فيتزلزلون زلزاال شديدا فيصبح فيهم عيسى ابن مريم ع)...

السالم فيهزمه هللا وجنوده حتى أن جذم الحائط وأصل الشجرة لينادى يا مؤمن هذا كافر يستتر بي فتعال

منها ولن يكون ذلك حتى ترو أمورا يتفاقم شأنها في أنفسكم تساءلون بينكم هل كان نبيكم ذكر لكمأقتله (ذكر وحتى تزول جبال عن مراسيها ثم على أثر ذلك القبض وأشار بيده

بما جاء في الفتن والمالحم وأشراط الساعة إتحاف الجماعةالشيخ حمود بن عبد هللا التويجري رحمه هللا

When we talk about robots doing the tasks of humans, we often talk

about the future.

But robotic surgery is already a reality.

The surgeon views the patient via a terminal and manipulates

robotic surgical instruments via a control panel.

The surgeon views the patient via a terminal and manipulates robotic surgical instruments via a control panel.

The difference between Endoscopic surgery (as laparoscopic surgery) and Robotic surgery is that

The instruments are controlled by the Robotic system in stead of the direct hold by the human (surgeon) hands

Robotics does not replace Human intelligenceSkillExperience

RobotSurgeon

Robotics does not replace Human intelligence, Skill andExperience

Should you be scared of robotic surgery?

Pedicle screw instrumentation : 1- Free hand (FH) conventional pedicle screw instrumentation15.3% error rate for 544 screws from T5 to S17 patients necessitated reoperation 4 patients sustained long-term neurological sequelae

2- Computer assisted navigation (CAN) and surgical robotics5.4% error rate for the 294 screwsNo patients required reoperation in the CAN groupNone experienced postoperative neurological deficits.

Navigation and Robotics in Spinal Surgery: Where Are We Now?Neurosurgery 80:S86–S99, 2017

VOLUME 80 | NUMBER 3 | MARCH 2017 Supplement www.Samuel C. Overley, MD∗, Samuel K. Cho, MD∗, Ankit I. Mehta, MD‡, Paul M. Arnold, MD§

∗The Mount Sinai Hospital, Icahn School of Medicine, New York, New York; ‡University of Illinois, Hospital and Health Sciences Center, Chicago, Illinois; §The University of Kansas Hospital, Kansas City, Kansas

These systems have the potential to improve the safety and effectiveness

of surgeries.

Three major advances aided by surgical robots:

Remote surgery,Minimally invasive surgery, and

Unmanned surgery.

ROBOTICAND

REMOTE SURGERY(TELESURGERY)

The story from the beginning

Evolution of fracture management

• Before 1950’s - External Splints & Fixation.

• After 1950’s - 1958 - Unstable internal fixation

• 1958 – 1960 ->> 1990 - Rigid internal fixation

Absolute mechanical stability (Aggressive Traumatology)

• After 1990’s - Biological Osteosynthesis Limiting Surgical trauma

(SIRS vs. CARS - 2nd Hit by surgery) 1- less invasive surgical techniques

2- Limited Implant contact

• After 2000 - Computer-assisted surgery (CAS or CAOS) utilizing Robotic or image-guided technologies

• Remote surgery (also known as Telesurgery)

Mechanical Internal fixation Learning

curve

BiologyBiochemistry

Computer, Space, 3D imaging, Anatomy,

Surgical approaches

Open Reduction Condemnedexcept in

Articular fracturesForearm fractures

CLOSED, INDIRECTREDUCTION

MINIMAL INVASIVEMIPO

LESS INVASIVELISSLCP

LCP (Preshaped implants)

KEY HOLE SURGERY(Endoscopic – Arthroscopic -

Laparoscpic)

MINIMAL INVASIVE PLATE OSTEOSYNTHESIS(MIPO)

MINIMAL INVASIVE PLATE OSTEOSYNTHESIS(MIPO)

MINIMAL INVASIVE PLATE OSTEOSYNTHESIS(MIPO)

The Biological new Surgical techniques

(Closed Reduction)

Needs

Alignment control

Alignment Control

LengthAngulation

Rotation

X-rays

Image Intensification

Computer Assistance

CLOSED, INDIRECTREDUCTION

MINIMAL INVASIVEMIPO

LESS INVASIVELISSLCP

LCP (Preshaped implants)

KEY HOLE SURGERY(Endoscopic – Arthroscopic -

Laparoscpic)

LENGTH

ANGULATIONCable Tech

ROTATION

Portable X-raysUnpractical

Image intensificationjust a real-time images

Image intensificationjust a real-time images

Computer Assisted Orthopedic Surgery

(CAOS)

1- Computer science2- Space digitization3- 3D Imaging technology4- Surgical techniques

1- Surgical navigation2- Robotic assistance

Reduction Maneuver Robot system

Surgical navigation

Robotic surgeryRemote surgery

(Telesurgery)

The surgeon instead of directly moving the instruments, He uses one of two methods to control the instruments;

1- Direct telemanipulator. A remote manipulator that allows the surgeon to perform the normal movements associated with the surgery (on simulator) whilst the robotic arms carry out those movements using end-effectors and manipulators to perform the actual surgery on the patient.

2- Computer control systemsThe surgeon uses a computer to control the robotic arms and its end-effectors, (these

systems can also still use telemanipulators for their input).

One advantage of using the computerized method is that the surgeon does not have to be present, but can be anywhere in the world, leading to the possibility for remote surgery.

Robotically-assisted minimally-invasive surgeryand Remote surgery (Telesurgery)

Robotic surgery

Robotic surgery is a type of minimally invasive surgery.

“Minimally invasive” instead of operating on patients through large incisions,

we use miniaturized surgical instruments that fit through a series of quarter-inch incisions.

Robotic surgery

The main object of such smart instruments is to reduce or eliminate the tissue trauma traditionally associated with open surgery without requiring more than a few minutes' training on the part of surgeons.

Why Robotic Surgery

A robot is not just a machine

It is an information system with arms

The robots are actually more accurate than Human beings

(Robotic Pedicular screws error 5% vs. 11% human experts vs. 40% human learning curve)

Total Integration of Surgical Care

Courtesy of Joel Jensen, SRI International, Menlo Park, CA

Minimally Invasive& Open Surgery

Pre-operative planningSurgical Rehearsal

Intra-operative navigation

Remote Surgery

Simulation & TrainingPre-operative Warm-up

APPLICATIONS

• Cardiac surgery

• Gastrointestinal surgery

• Gynecology

• Neurosurgery

• Orthopedics

• Pediatrics

• Radio surgery

• Urology

Different procedures, including:Coronary artery bypassCutting away cancer tissue from sensitive parts of the body such as blood vessels, nerves, or important body organsGallbladder removalHip replacementHysterectomyKidney removalKidney transplantMitral valve repairPyeloplasty (surgery to correct ureteropelvic junction obstruction)PyloroplastyRadical prostatectomyRadical cystectomyTubal ligation

Da Vinci Surgical System

ZEUS Robotic Surgical System

AESOP Robotic System

There are three surgical robots that have been recently developed

Surgical Robot - “Da vinci”4 arms

• Da vinci’s miniaturized instruments are mounted on three separate robotic arms, allowing the surgeon maximum range of motion and precision. The da Vinci’s fourth arm contains a magnified high-definition 3-D camera that guides the surgeon during the procedure.

Da vinci is the one of the most advanced Surgical bot in the world.

ES159/259

Da Vinci SystemVideodisplay

patient

surgeon

Robot arms

console

Da Vinci robot consists • A surgical console• Patient- side cart

• Instruments and imaging processing equipment

The surgeon views the patient via a terminal and manipulates robotic surgical instruments via a control panel.

Da Vinci Components

Surgeon’s Console

• Optimal hand-eye alignment• Immersive 3D stereo viewer• Comfortable seat posture – ergonomic• Motion scaling & tremor reduction

Master controller controls the motion of the end effector wrist

Da vinci Cart

•Endowrist instruments

•3-4 robotic arms

•Interchangeable end

effectors

Da Vinci Components

Da Vinci System

• Multiple robotic arms

– For camera control and end effector control

Stereo endoscope

Tools at arms of bot

The Endoscope

• Fiber optic instrument

• Inserted through a small incision

• Has a very tiny video camera

• Shows the surgeon a 3-dimensional, magnified view

• Projects to a television screen

Speciality of Da vinci

The surgeon controls these instruments and the camera from a console located in the operating room. Placing his fingers into the master controls, he is able to operate all four arms of the da Vinci simultaneously while looking through a stereoscopic high-definition monitor that literally places him inside the patient, giving him a better, more detailed 3-D view of the operating site than the human eye can provide

Robotic and Remote surgery (Telesurgery)

Robotic surgery is a type of rapidly advancing minimally invasive

surgery.

A robot is not just a machine

It is an information system with arms

The robots are actually more accurate than Human beings

• Surgeons have enhanced view

• Easier to attach nerve endings

• Surgeons tire less easily

• Fewer doctors required in operating rooms

• In turn, cheaper for hospitals.

• Smaller risk of infection

• Less anesthesia required

• Less loss of blood

Benefits of Robotic Surgery (Operative)

Benefits of Robotic Surgery (Post operative)

• Operations through small tiny incisions less scarring

• Faster recovery time

• Reduce loss of healthy tissue

• Less pain, shorter hospital stay

• Reduced cost

• Patient returns to work sooner

• Greater surgical precision

• Less blood loss and transfusion.

• Time lag between surgeons commands and action of robot could harm the patient (fiber optic)

• Loss of power in an electrical failure

• Robotics does not replace humanintelligence, skill and experience

• Surgericals Robots are much

costlier - Da vinci's cost is 2.5 million euro.

Legal/Ethical issue in Robotic surgery

• The rate of discovery of new technology is outpacing the ability of business, society, and healthcare to integrate and apply

• Robotic surgery is but one example of such technology that may reduce operative morbidity, hospital stay, and recovery, while potentially improving clinical outcomes

• But at what point do the benefits justify the increased expense?

Legal/Ethical issue in Robotic surgery

Figure 1. Annual Numbers of Adverse Event Reports and Rates of Events per ProcedureThe left Y-axis corresponds to the bars showing the absolute numbers of adverse events (based on the year thatreports were received by the FDA). The right Y-axis corresponds to the trend lines showing (in logarithmic scale)the annual number of adverse events per 100,000 procedures (based on the year the events occurred). Numbers onthe bars indicate number of deaths reported per year. Error bars represent 95% confidence intervals for theproportion estimates. Because of the small number of injury and death events reported for 2004 and 2005, acombined rate was calculated for 2004–2006. Note that of all the events, 40 were reported as part of the articles orthe legal disputes received by the manufacturing company.

DISADVANTAGES

The Question of

Safety & Cost

During the study period

1- 144 deaths (1.4% of the 10,624 reports)

2- 1,391 patient injuries (13.1%)

3- 8,061 device malfunctions (75.9%) were reported

14 year period of 2000–2013 Adverse Events in Robotic Surgery:

A Retrospective Study of 14 Years of FDA Data

specialties, for which robots are extensively used, such as gynecology and urology, had lower number of injuries, deaths, and conversions per procedure

than more complex surgeries, such as cardiothoracic and head and neck

Device and instrument malfunctions, such as

falling of burnt/broken pieces of instruments into the patient (14.7%), electrical arcing of instruments (10.5%), unintended operation of instruments (8.6%), system errors (5%), and video/imaging problems (2.6%), constituted a major part of the reports.

Device malfunctions impacted patientsin terms of injuries or procedure interruptions. In 1,104 (10.4%) of the events, the procedure was interrupted to restart the system (3.1%), to convert the procedure to non-robotic techniques (7.3%), or to reschedule it to a later time (2.5%)

8,061 device malfunctions (75.9%) were reported

Figure 2. Cumulative rates of malfunctions per procedureThe rates of malfunctions per procedure were obtained for each week (see Figure 2 in Appendix for more details).

LimitationsThe results of our study come with the caveats that inherent risks exist in all surgical procedures (more so in complex procedures) and that the MAUDE database suffers from underreporting and inconsistencies.Thus, the estimated number of adverse events per procedure are likely to be lower than the actualnumbers in robotic surgery. Further, the lack of detailed information in the reports makes it difficult to determine the exact causes and circumstances underlying the events. Therefore, the sensitivity of adverse event trends to changes in reporting mechanisms, surgical team expertise, and inherent risks of surgery could not be assessed here.

Despite widespread adoption of robotic systems for minimally invasive surgery, a non negligible number of technical difficulties and complications are still being experienced during procedures. Adoption of advanced techniques in design and operation of robotic surgical systems may reduce these preventable incidents in the future.Copyright © 2015: Authors.

While the robotic surgical systems have been successfully adopted in many different specialties, this study demonstrates several important findings: (1) the overall numbers of injury and death events per procedure have stayed relatively constant over the years, (2) the probability of events in complex surgical specialties of cardiothoracic and head and neck surgery has been higher than other specialties, (3) device and instrument malfunctions have affected thousands of patients and surgical teams by causingcomplications and prolonged procedure times.As the surgical systems continue to evolve with new technologies, uniform standards for surgical team training, advanced human machine interfaces, improved accident investigation and reporting mechanisms, and safety-based design techniques should be developed to reduce incident rates in the future.

روا به ا نسوا ما ذك م أبو فلم حوا ب اب كل شيء فتحنا عليه ما أوتوا أخذناهم حتى إذا فر

بلسون (44) بغتة فإذا هم م

سورة األنعام

So when they forgot that by which they had been reminded, We opened to them the doors of every [good] thing until, when

they rejoiced in that which they were given, We seized them suddenly, and they were [then] in despair.

Reviewing the history of mankind's cumulative experience starting with the ancient very

primitive trials and ending with the presence of Robotic and Telesurgery

Clearly show that the major and rapid advances in the whole mankind's life occur

only in the last few decades especially the last 10 years ?

REFERENCES

• http://en.wikipedia.org/wiki/Robotic_surgery

• http://www.medicalnewstoday.com/articles/153737.php

• http://robotic-surgery.med.nyu.edu/for-patients/what-robotic-surgery

• http://www.healthcommunities.com/female-cancers/what-is-a-gynecologic-oncologist.shtml

• http://www.davincisurgery.com