Running head: ROBOTS IN DISGUISE
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Robots in Disguise
Megan Davis
Ferris State University
English
321
Dr. Amidon
May 02, 2013
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Table of Contents
Abstract…………………………………………………………………............................3
What Makes up the Robot…………………………………………………………………4
Urological Robotic Surgeries……………………………………………………………...6
Robotic Prostatectomy…………………………………………………………………….6
Gynecological Robotic Surgeries…………………………………………………………8
Robotic Hysterectomy…………………………………………………………………….9
Conclusion……………………………………………………………………………….10
Glossary………………………………………………………………………………….11
References…………………………………………………………………………….….12
Endorsements…………………………………………………………………………….14
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Abstract
This paper explores the extensive developments made by robotic assisted surgeries.
Robotic-assisted laparoscopic surgeries are to be compared to the traditional open surgeries.
Robotic-assisted laparoscopic surgeries will never replace traditional laparoscopic surgeries.
They are meant to replace laparotomies. Robotics allow patients that would need an open surgery
had to a laparoscopic procedure. This paper discusses in detail the benefits of robotic
prostatectomies and hysterectomies. With a robotic-assisted laparoscopic surgery patient have
less blood loss, a shorter hospital stay, use less narcotic pain medications, and offer other
benefits. Robotic-assisted laparoscopic surgeries have less complications for the patient and
allows them to return to their normal actives sooner.
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Robots in Disguise
Robotics are making enormous strides in surgery. Robotics are the future of surgery. In the last
ten years robotic surgery has become more prevalent. Robotic surgeries are being performed all
over the world, as well as right here in West Michigan. All three of the hospitals in Grand Rapids
have at least one Da Vinci Robot. For the last two years, I have worked as part of the robotic
surgery team at Metro Health. It is truly astounding to see the robot functioning during a surgical
procedure. Robotic surgery is being used for Urology, Gynecology, General surgery, Cardiac,
Colon rectal, Head and Neck, and Thoracic. This paper will discuss prostatectomies and
hysterectomies two of the most common robotic surgeries. Robotic assisted laparoscopic
surgeries are replacing open surgeries. Robotic surgery allows for a broader spectrum of patients
to have their procedure done laparoscopic versus open. Without robotic surgery numerous
patients with significantly large tumors, a high body mass index, or with excessive adhesions
would require a large traditional incision. Robotic surgeries decrease blood loss, patients have a
shorter hospital stay and use less narcotic pain medication following surgery. All of these
making surgery better for the patient which is always the main focus of the operating room.
What Makes up The Robot
Intuitive Surgical Inc. was founded in 1995. The first version of the Da Vinci system was
launched in 1999. In July 2000, the device received US Food and Drug Administration approval
for laparoscopic surgery. Intuitive is the company that makes the Da Vinci robot. The Da Vinci
robot is the only surgical robot. The Da Vinci robot consists of three to four pieces. The first
piece is the console, which is where the surgeon sits and performs the surgery. In the United
States, the FDA requires the console to be in the same room as the patient. The console consists
of a stereo viewer that is controlled by an infrared sensor. The system is activated when the
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surgeon’s head is in the console and the arms come to life. If the surgeon’s head is removed
immediate deactivation occurs, and the robotic arms are locked in place. This is a very useful
safety mechanism. The surgeon views the inside of the patient body in three-dimensional and
high definition. For the surgeon looking thru the Da Vinci 3D imaging system it is very similar
to looking through field binoculars. What the surgeon sees is just like looking into the body of an
open procedure. The surgeon’s hands go into free-moving finger controls. These controls convert
the movement of the fingertips and wrist into electrical signals. These are then translated to
computer commands that allow the robot to mirror the movements in the operative field. (Patel,
2007) Several hospitals have two consoles for each robot they own: One for the attending
surgeon and the second for surgical residents. The attending surgeon is able to mark the screen
exactly where to cut or cauterize. Both the attending and the resident are able to perform surgery
interchangeably. There is also a simulator on the console so the physician can practice their skills
with different exercises. The second piece is the patient side cart, the arms of the robot. This
piece of the robot is right up by the patient. There are three arms to hold the many different
instruments that may be used in addition to the arm that holds the camera. An incredible
advantage to the Da Vinci instrument compared to traditional laparoscopic instruments is that
they rotate 360 degrees versus 180 degrees. Robotic surgery carries with it the potential to
transform laparoscopic surgery by providing, for the first time, instruments with distal ends that
mimic the intricate movements of the human hand while at the same time providing the surgeon
with a high-definition, three-dimensional view of the operative field. (Visco & Advincula,
2008)There are a total of four arms, not all surgeons or surgeries have a need for all of them. The
arms attach to the ports which are in the patient. Each port site is about a 2-3 cm incision. The
patient will always have a least one port, but could have up to four ports. Even with four ports,
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the incisions are significantly smaller than a traditional open incision. The last part of the robot is
the high-definition, three-dimensional vision system. The vision system houses the camera, light
sources, and a monitor. All three of the other pieces of the robot connect to the vision system by
cords. This is how the robot communicates with each piece. The monitor acts like a television so
that others in the room can see the procedure. The monitors are helpful for medical students and
residents to be able to watch the surgeon work. With a traditional open surgery you can only fit
so many people around the sterile field. With the monitors, multiple people can watch and learn.
This is a brilliant education piece for staff and students.
Urological Robotic Surgeries
A new category of surgery enabled by the Da Vinci surgical system is being used by an
increasing number of surgeons around the world. Urological procedures being performed
robotically include prostatectomy, cystectomy, pyeloplasty, and partial nephrectomy. Robotics
are making immense stride for urological surgeries. There are phenomenal benefits to robotic
procedures versus open procedures. Robotics are proving these patients with a less complicated
procedure and allowing them to return to a better quality of life sooner.
Robotic Prostatectomy
Robotic radical prostatectomy is a promising technical revolution that allow surgeon to
overcome many of the inherent limitations of laparoscopic surgery. Robotic-assisted
laparoscopic prostatectomy (RALP) is the most commonly performed robotic operation in the
world. (Patel, 2007) Prostatectomies are the most established robotic surgery. Robotic
prostatectomies are less invasive, have less blood loss, involve a shorter hospital stay, and a
shorter catheter duration than radical retropubic prostatectomies (RRP). Most patients with
localized carcinoma of the prostate are good candidates for either open or robotic-assisted
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laparoscopic prostatectomy. How does the surgeon decide which patients are a better candidate
for robotic surgery? There are several criteria that makes one surgical approach preferable over
others in some patients. Obesity can limit access in both the laparoscopic approaches. In obese
patients, long ports can be used which allow the Da Vinci instruments to have deeper access in
the body. The instruments also rotate 365 degrees, unlike traditional laparoscopic instruments.
This allows the surgeon a better chance of performing the procedure robotically. The size of the
prostate is also a consideration. Larger prostates can be removed with fewer complications
robotically than laparoscopic. A history of a prior abdominal surgery can be less complicated if
performed with the robot. Especially if the surgery used mesh, for, with prior inguinal hernia
repair. With previous abdominal surgery there is a higher chance that the patient will have
abdominal adhesion or scar tissue. The adhesions have to be taken down before the surgery can
continue. Lysis of adhesion is done with less complication for the surgery if done robotically.
There have been multiple studies done looking at perioperative and postoperative
outcomes. One study done between RRP and RALP looked at blood loss. During a 14 month
period, 279 patients with localized carcinoma of the prostate were prospectively enrolled in this
comparative study. Of the 279 patients, 176 underwent RALP and 103 underwent RRP. Patients
in the RALP group had significantly less intraoperative blood loss compared with the RRP group
(mean 191 ml versus 664 ml). Also, in the same study they looked at the patient discharge
hematocrit. In support with decreased blood loss during surgery, the RALP group had a higher
hematocrit of 36.8 versus the RRP group whose hematocrit was 32.8. (Farnham, Webster,
Herrell, & Smith, 2006) Another study done between January 2003 and May 2005 showed that
143 patient with clinically localized prostate cancer underwent a robotic radical prostatectomy.
Mean operative time was 241 minutes with an estimated blood loss (EBL) of 247 ml, 3% of
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patients required conversion to open surgery. The average hospitalization was 1.8 days, and the
Foley catheters were removed after 8.9 days. (Raman, Dong, Levinson, Samadi, & Scherr, 2007)
To compare one more study that validates that robotic are the future of surgery. 100 patient
underwent radical retropubic prostatectomy and 200 underwent robotically assisted
prostatectomy. The duration of the operation and the pathological stages were comparable. There
were significant differences in the measured outcome. The blood loss was 910 ml and 150 ml for
RRP and RALP. The transfusion rate was higher for the RRP, which you would expect with the
greater blood loss. There were four times as many complications after RRP (20% vs. 5%). Again
the hospital stay was about 2- 3 time longer (3.5 vs. 1.2 days). Also 93% of robotic patient were
discharged within 24 hours. Catheterization was twice as long after RRP (15.8 vs.7days). After
robotic prostatectomies patients achieved continence and return of erection more quickly than
after RRP (160 vs. 44 and 180 vs. 440 days). (Menon, 2003)
After reading these studies it is very apparent that robotics have made enormous strides in
urology. All of the improvements in robotics benefit the patients. There is a significant amount
of research that supports better patient outcomes with robotic prostatectomies. Patients have a
shorter length of stay in the hospital. Patients have less blood loss, shorter catheter time, and
achieved continence soon. These are just some of the advantages to robotic prostatectomies.
After reviewing the pros and cons of robotic prostatectomies it is evident patients have less
complications robotically.
Gynecological Robotic Surgery
The Da Vinci robot was approved for use in gynecological procedures in the United
States in 2005. (Hemal & Menon, 2011) Robotic-assisted laparoscopic surgeries in gynecology
include: benign hysterectomy, myomectomy, tubal reanastomosis, radical hysterectomy, lymph
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node dissections, sacrocolpopexy, vesicovaginal fistula repairs, and treatment of endometriosis.
The benefits of these procedures being done robotically are: reduced hospital stay, decreased
pain, and faster recovery. Robotic assistance represents technical advancements that improve
upon the benefits of traditional laparoscopy. Some restrictions with traditional laparoscopies are
counterintuitive hand movements, two-dimensional imagining, and limited degrees of instrument
movement within the body. Gynecologist that perform laparoscopic procedures work within a
confined space of the female pelvis. One major obstacle to the acceptance and application of
minimally invasive surgeries for gynecology has been the steep learning curve for surgeons.
Robotic Hysterectomy
Hysterectomies are a very common procedure being done robotically. Patients that have
robotic-assisted laparoscopic surgeries have a shorter hospital stay, significant decrease in
narcotic use, and less complications for the patient. There are a few studies to review the many
benefits of robotic hysterectomies. This study compared patient characteristics, operative
variables, and outcomes of 24 patients who underwent robotic-assisted total laparoscopic
hysterectomy with 44 patients who underwent total laparoscopic hysterectomy (TLH). The
robotic TLH was associated with a shorter hospital stay (1.0 vs. 1.4 days). A significant decrease
in narcotic use (1.2 vs. 5.0 units). Estimated blood loss and drop in hemoglobin were not
significantly different. Conclusion: robotic hysterectomies postoperative measures were
improved over measures for conventional laparoscopy. (Shashoua, Gill, & Locher, 2009)
Another study compared robotic hysterectomies versus laparoscopies and laparotomies. Results
showed the mean operating times for patient undergoing robotic, laparoscopy, and laparotomy
radical hysterectomy were 189.6, 220.4, and 166.8 minutes. Blood loss was 133.1, 208.4, and
443.6ml. The mean length of hospital stay was 1.7, 2.4, and 3.6 days. Conclusion: laparoscopy
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and robotics are preferable to laparotomy for patients requiring a radical hysterectomy.
Operating times for robotics and laparotomy were similar, and significantly shorter as compared
to laparoscopy. Blood loss and length of hospital stay were similar for laparoscopy and robotics
and significantly reduced as compared to laparotomy. (Magrina, Kho, Weaver, Montero, &
Magtibay, 2008) Both of the study show that robotics are the way of the future in hysterectomies.
Robotics hysterectomies have safer and better outcomes for patients. Less complication and safer
outcomes are always a priority in the operating room.
Conclusion
The Da Vinci robotic has made colossal strides since 2000 when the Da Vinci was
approved by the FDA. Only prostatectomies and hysterectomies were discussed at length, but the
reach supports robotic surgeries for these procedures having fewer complications. After reading
this paper it’s obvious there are several benefits for the patient if the surgery is performed
robotically. When comparing robotic surgeries versus open surgeries, patients had less blood
loss, a shorter hospital stay, and several other benefits. Patients had less complications with
robotic surgeries. Patients were able to return back to normal activities sooner.
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Glossary
Hematocrit: The percentage by volume of packed red blood cells in a given sample of blood after
centrifugation.
Hemoglobin: (Hb) The iron-containing respiratory protein in red blood cells, responsible for
transporting oxygen from the lungs to the rest of the body.
Hysterectomy: Surgery to remove all parts of the uterus.
Laparotomy: A surgical incision into the abdominal cavity, for diagnosis or in preparation for
major surgery.
Prostatectomy: Surgery to remove all parts of the prostate gland.
Radical Retropubic Prostatectomy: Is a surgical procedure in which the prostate gland is removed
through and incision in the abdomen.
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References
Farnham, S. B., Webster, T. M., Herrell, S. D., & Smith, J. A. (2006, February). Intraoperative
blood loss and transfusion requirement for robotic assisted radical prostatectomy versus
radical retropubic prostatectomy. Urology, 67, 360-363. Retrieved from
http://www.ncbi.nim.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&dopt=Citati
on&list uids=16461085.
Hemal, A. K., & Menon, M. (Eds.). (2011). Robotic Surgery in Urogynecology. Robotics in
Genitourinary in Surgery (pp. 605-610). New York, USA: Springer London Dordrecht
Heidelberg.
Magrina, J. F., Kho, R. M., Weaver, A. L., Montero, P. R., & Magtibay, P. M. (2008). Robotic
radical hysterectomy: comparison with laparoscopy and laparotomy. Journal of
Gynecologic Oncology, 109, 86-91. Retrieved from
http://www.davincisurgerycomminity.com.
Menon, M. (2003, August). A prospective comparison of radical retropubic and robotic-assisted
prostatectomy: experience in one institution. Journal of the British Association of
Urological Surgeons, 92, 205-210.
Patel, V. R. (Ed.). (2007). Robotic Urologic Surgery. : Springer-Verlag London.
Raman, J. D., Dong, S., Levinson, A., Samadi, D., & Scherr, D. S. (2007, July 27). Robotic
Radical Prostatectomy: Operative Technique, Outcomes, and Learning Cure. Journal of
the Society of Laparoendoscopic Surgeons, 11(1-7), 1-7. Retrieved from
hppt://www.ncbi.nlm.nih.gov/pmc/articles/PMC3015817.
Shashoua, A. R., Gill, D., & Locher, S. R. (2009). Robotic-assisted total laparoscopic
hysterectomy versus conventional laparoscopic hysterectomy. Journal of the Society of
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Laparoendoscopic Surgeons, 13, 364-369. Retrieved from
http;//www.scopus.com/inward/record.uri?eid=2-s2.0-70350327368&partneriD=40.
Visco, A. G., & Advincula, A. P. (2008, December). Robotic Gynecologic Surgery. Journal of
Obstetrics and Gynecology, 112, 1369-1384.
http://dx.doi.org/10.1097/AOG.ob013e31818f3c17.
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Endorsements
Great job Megan! I did not know very much about Robotic surgery.......Holy cow!
I have read Megan Davis's paper on Robotic Surgery. I found it to be very informative and
gained a lot of knowledge about the surgeries performed with the Da Vinci and the positive
outcomes for the patients. It was a well research and written paper.
Diana VanRhee RN, SPR Metro Health Hospital
Megan,
I enjoyed reading your paper on robotic surgery. It is accurate and demonstrates the
wide range of uses in the surgical arena, plus describes the benefits of robotically
assisted laparoscopic surgeries over the open surgical approach.
It is professionally written with good use of sources.
Thank you for allowing me to preview your paper.
Denice Clifton RN CNOR BS
Robotic Surgery Clinical Specialist
Metro Health Hospital
I had the pleasure of reviewing Megan's research paper. I was immediately impressed with the
amount of information that Megan produced about the Da Vinci robot. I had no idea how
extravagant and intricately detailed the robotics work. I have gained a wealth of information on
risks and benefits of having surgery performed with the Da Vinci robot. I think this paper was
very well written and very informative. Megan did a great job explaining the Da Vinci robot and
the two surgeries that benefit greatly which are prostatectomies and hysterectomies. Good job.
Kimberly McPike RN
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Thank you for the opportunity to read and review your paper on Robotic Procedures. As my
practice is primary focused in the division of critical care I was not aware of the fundamental
underpinnings of Robotic procedures. In my opinion, I found your paper to be clear, concise,
well organized and easy to read. From the table of contents to the conclusion, you displayed
rational, organized thinking in the way you presented the content. The references you chose are
up to date and evidenced based. Thank you for letting me review this paper and look forward to
doing it again.
Patti
Patricia L. Carlton MSN, RN
Clinical Education Specialist
Critical Care
Rhode Island Hospital
Center for Practice Excellence