Robotics, Technology, and the Future of Surgery
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Auteurs : Michael S. KavicSource :
- JSLS : Journal of the Society of Laparoendoscopic Surgeons [ 1086-8089 ] ; 2000.
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PubMed: 11051184
PubMed Central: 3113187
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<record><TEI><teiHeader><fileDesc><titleStmt><title xml:lang="en">Robotics, Technology, and the Future of Surgery</title><author><name sortKey="Kavic, Michael S" sort="Kavic, Michael S" uniqKey="Kavic M" first="Michael S." last="Kavic">Michael S. Kavic</name></author></titleStmt><publicationStmt><idno type="wicri:source">PMC</idno><idno type="pmid">11051184</idno><idno type="pmc">3113187</idno><idno type="url">http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3113187</idno><idno type="RBID">PMC:3113187</idno><date when="2000">2000</date><idno type="wicri:Area/Pmc/Corpus">000D39</idno><idno type="wicri:Area/Pmc/Curation">000D39</idno></publicationStmt><sourceDesc><biblStruct><analytic><title xml:lang="en" level="a" type="main">Robotics, Technology, and the Future of Surgery</title><author><name sortKey="Kavic, Michael S" sort="Kavic, Michael S" uniqKey="Kavic M" first="Michael S." last="Kavic">Michael S. Kavic</name></author></analytic><series><title level="j">JSLS : Journal of the Society of Laparoendoscopic Surgeons</title><idno type="ISSN">1086-8089</idno><idno type="eISSN">1938-3797</idno><imprint><date when="2000">2000</date></imprint></series></biblStruct></sourceDesc></fileDesc><profileDesc><textClass></textClass></profileDesc></teiHeader><back><div1 type="bibliography"><listBibl><biblStruct><analytic><author><name sortKey="Schurr, Mo" uniqKey="Schurr M">MO Schurr</name></author><author><name sortKey="Buess, G" uniqKey="Buess G">G Buess</name></author><author><name sortKey="Neisius, B" uniqKey="Neisius B">B Neisius</name></author><author><name sortKey="Voges, U" uniqKey="Voges U">U Voges</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Satava, Rm" uniqKey="Satava R">RM Satava</name></author><author><name sortKey="Jones, Sb" uniqKey="Jones S">SB Jones</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Sackier, Jm" uniqKey="Sackier J">JM Sackier</name></author><author><name sortKey="Wang, Y" uniqKey="Wang Y">Y Wang</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Schneider, I" uniqKey="Schneider I">I Schneider</name></author></analytic></biblStruct></listBibl></div1></back></TEI><pmc article-type="editorial"><pmc-dir>properties open_access</pmc-dir>
<front><journal-meta><journal-id journal-id-type="nlm-ta">JSLS</journal-id><journal-id journal-id-type="iso-abbrev">JSLS</journal-id><journal-id journal-id-type="hwp">jsls</journal-id><journal-id journal-id-type="pmc">jsls</journal-id><journal-id journal-id-type="publisher-id">JSLS</journal-id><journal-title-group><journal-title>JSLS : Journal of the Society of Laparoendoscopic Surgeons</journal-title></journal-title-group><issn pub-type="ppub">1086-8089</issn><issn pub-type="epub">1938-3797</issn><publisher><publisher-name>Society of Laparoendoscopic Surgeons</publisher-name><publisher-loc>Miami, FL</publisher-loc></publisher></journal-meta><article-meta><article-id pub-id-type="pmid">11051184</article-id><article-id pub-id-type="pmc">3113187</article-id><article-categories><subj-group subj-group-type="heading"><subject>Editorial</subject></subj-group></article-categories><title-group><article-title>Robotics, Technology, and the Future of Surgery</article-title></title-group><contrib-group><contrib contrib-type="author" corresp="yes"><name><surname>Kavic</surname><given-names>Michael S.</given-names></name><degrees>MD</degrees><role>Editor-in-Chief</role></contrib><aff>Department of Surgery, Northeastern Ohio Universities College of Medicine, Rootstown, Ohio. Department of Surgery, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania.</aff></contrib-group><author-notes><corresp>Address reprint request to: Michael S. Kavic, MD, FACS, <addr-line>St. Elizabeth Health Center, Surgical Education, 1044 Belmont Ave, PO Box 1790, Youngstown, OH 44501-1790, USA</addr-line>. Telephone: <phone>(330) 480-3124</phone>, Fax: <fax>(330) 480-3640</fax>, E-mail: <email>MKavic@aol.com</email></corresp></author-notes><pub-date pub-type="ppub"><season>Oct-Dec</season><year>2000</year></pub-date><volume>4</volume><issue>4</issue><fpage>277</fpage><lpage>279</lpage><permissions><copyright-statement>© 2000 by JSLS, Journal of the Society of Laparoendoscopic Surgeons.</copyright-statement><copyright-year>2000</copyright-year><copyright-holder>Society of Laparoendoscopic Surgeons, Inc.</copyright-holder><license license-type="open-access"><license-p>This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial No Derivatives License (<ext-link ext-link-type="uri" xlink:href="http://creativecommons.org/licenses/by-nc-nd/3.0/">http://creativecommons.org/licenses/by-nc-nd/3.0/</ext-link>), which permits for noncommercial use, distribution, and reproduction in any medium, provided the original work is properly cited and is not altered in any way.</license-p></license></permissions><self-uri xlink:title="pdf" xlink:type="simple" xlink:href="jsls-4-4-277.pdf"></self-uri></article-meta></front><body><p>Technology and the creative use of the newly developed solid state, charge coupled device (CCD) cameras, laparoscopes, clip appliers, and energy sources enabled the laparoscopic revolution of the 1990s. And, without doubt, evolving technology will sustain the development of minimally invasive surgery. But the technology that fueled the laparoscopic revolution is aged and now hinders further advances in the field.</p><p>In particular, several characteristics inherent to laparoscopic surgery have slowed its more general diffusion into the surgical mainstream. These characteristics include:
<list list-type="order"><list-item><p>The requirement of laparoscopic surgery for highly trained personnel to maintain instruments and to assist during an operative procedure;</p></list-item><list-item><p>Expensive instrumentation (particularly disposables);</p></list-item><list-item><p>Poor ergonomic design of laparoscopic instruments;</p></list-item><list-item><p>Two-dimensional video representation of the real-world, 3-dimensional operative field;</p></list-item><list-item><p>Work environment not conducive to operator comfort:</p><list list-type="alpha-lower"><list-item><p>poor monitor placement</p></list-item><list-item><p>inefficient operating instruments sited remote from the operative site</p></list-item><list-item><p>limited ability to steer rigid laparoscopic instruments</p></list-item></list></list-item><list-item><p>Lack of haptic (touch) sense;</p></list-item><list-item><p>Surgeon dependence upon a camera operator for visualization of the operative field.</p></list-item></list></p><p>These characteristics are hindrances to the diffusion of minimally invasive surgery, but they are not insurmountable problems. Rather, they are challenges. Disposable instruments can be made in a reusable format with significant cost savings. Personnel can be cross-trained and used more efficiently. Three-dimensional laparoscopic cameras are available and can be further refined. These remedies, however, are only “quick fixes.” A more complete solution is needed for a comprehensive transition to minimally invasive surgery and, ultimately, for the evolution to noninvasive, image-guided therapies.</p><p>Operating rooms (OR) designed for open surgery of the mid-20th century have not been easily adapted to a laparoscopic environment. Frequently floors of rooms used for laparoscopic surgery are cluttered with cables and wires connecting video monitors, light generators, and energy sources. Tubes linking suction devices to suction-aspirators and oxygen lines add to the confusion. Towers containing insufflation devices, video recorders, fiberoptic light sources, and monitors are cumbersome and difficult to move. More wires and tubes connect the patient to anesthetic delivery machines and monitoring devices. The technologies have been “added on” rather than “integrated into” the operating theater, and the “added on” look is very evident in a typical operating room.</p><p>The human arm and hand, although a marvelous device for the performance of specific tasks, is another unit that has not adapted well to laparoscopic surgery. The armhand unit has 7 degrees of freedom (DOF) that allows the hand to be precisely manipulated in 3-dimensional space. However, during minimally invasive surgery, cannula diameter forbids ingress of a hand into the operative field and laparoscopic instruments must be substituted for it. First generation laparoscopic instruments have been a poor substitute for the hand and are limited in range to 4 degrees of freedom. The first 2 degrees of freedom concern rotation of the laparoscopic instrument around the point of insertion in the X and Y planes. The third degree of freedom involves rotation around the shaft axis of the instrument. The fourth degree of freedom is a translation (in-and-out) movement of the instrument.<sup><xref ref-type="bibr" rid="B1">1</xref></sup> Despite advances in instrument design, standard laparoscopic instrumentation at the beginning of the 21st century yet permit only 4 degrees of freedom.</p><p>Consequently, little question exists that the future demands a new approach to these problems. It should be noted that just as medicine transitioned from an agrarian age to the Industrial age a century ago, a transition from the Industrial Age to the Information Age is occurring today. It is reasonable, therefore, to suppose that a new approach to solving the current problems of minimally invasive surgery lies with the application of information technologies. Information technologies can be categorized as devices that acquire information, devices that process and transmit information, and those technologies and devices that cause a therapeutic intervention.<sup><xref ref-type="bibr" rid="B2">2</xref></sup></p><p>A great deal of what a physician does on a daily basis involves information management. For example, a laparoscopic surgeon looks at a video representation of human organs during a surgical procedure on those organs rather than at the actual organs themselves. Vital signs, laboratory data, and radiographs can be represented in a digital format. Doppler ultrasound can give a “false color” image of blood flow. Charting can be performed on a computer. All of this interaction involves information technologies and the substitution of information for real-world objects. In effect, “blood and guts” are converted to “bits and bytes.”</p><p>Information technology and information equivalents, therefore, may be used to resolve some of the hindrances inherent with minimally invasive surgery. For example, robots (the term was first used in Capek's 1920 play, Rossum's Universal Robots, and is derived from the Czechoslovakian word Robata, meaning “forced labor”) can be used to replace human surgical assistants.<sup><xref ref-type="bibr" rid="B3">3</xref></sup></p><p>Several devices are available to secure and manipulate a laparoscope replacing the camera operator. AESOP (Automated Endoscopic System for Optimal Positioning) is such a device and can be made available to recognize voice commands. The system facilitates a laparoscopic procedure by abolishing the need for an assistant, provides stability of view, is associated with less inadvertent smearing of the lens, and results in less fatigue of the operative team. Visualization of the operative field is under direct control of the surgeon. Savings occur in time, and, after the initial expense of the purchase, savings are associated with the reduction in human personnel required to perform the procedure.</p><p>Hermes is an another device that can enhance the performance of a laparoscopic surgeon. Hermes is a voiceactivated system that recognizes spoken commands to, among other things, adjust lighting in the operating room, adjust the operating table, contact another doctor, or gather information on the Internet. A wealth of information and databases can be made available to the surgeon during the procedure, in real-time, to improve patient care.</p><p>Scaling, which is a specific control feature of advanced manipulator systems, can allow the ratio between the input and output movement of the system to be changed. The capability to scale movement and force either upward or downward is available to the surgeon and results in a more exquisite control of the surgical procedure. This technology compliments and enhances human performance as demonstrated by Zeus, one example of an advanced manipulator system.</p><p>Zeus is a remote-controlled robot that can perform surgical intervention. This device incorporates 3 remote-controlled interactive arms: one voiceactivated arm to control the laparoscope and 2 robotic arms to manipulate purpose-designed instruments. The instruments at the end of the robotic arms are controlled with a joystick at the surgeon's workstation. Built-in tremor control (a signal-filtering technique that operates through the computer interface) dampens the natural tremor present in a human hand and allows for greater control of the surgical instruments.</p><p>Similarly, the da Vinci Surgical System combines robotics and computer imaging to enable microsurgery in a laparoscopic environment. The system consists of a surgeon's viewing and control console (workstation) integrated with a high-performance, 3-dimensional monitor system, a patient side-cart consisting of 3 robotic arms that position and maneuver endoscopic instruments, an endoscope, and a variety of articulating instruments. The surgeon's hand, wrist, and finger movements are translated into corresponding micro-movements within the patient's body. Haptics are employed to reproduce the surgeon's hand movements in real-time and allow precise movements in small spaces. The ability to perform precise movements enable endoscopic coronary-artery-bypass procedures on a beating heart and could enable improved microsurgery for nerve-related operations such as prostatectomy. Preservation of the sex nerves to the prostate and preservation of the muscles that control urination offer the possibility of a significant advance in the performance of radical prostatectomy. The da Vinci system has obtained FDA clearance.<sup><xref ref-type="bibr" rid="B4">4</xref></sup></p><p>With these advanced manipulator systems, the surgeon sits remote from the patient at an operating console adjusted to provide an optimal ergonomic environment. Surgery can be performed from the room next to the patient or from a location many miles away. Being able to operate at a workstation remote from the patient obviously has benefits in providing advanced surgical care to patients in underserved areas and when operating on patients with highly communicable diseases. In the latter instance, the risk of disease transmission is decreased when an operating team can be more completely protected from exposure to contagious tissue and body fluids.</p><p>The future of surgery is bright and is pregnant with promise. Robots and the use of information technologies can result in cost savings by decreasing the number of skilled assistants required to perform laparoscopic surgery. Newly developed, articulated robotic arms have an increased number of degrees of freedom that mimic many of the functions of the human hand and, in some instances, improve on those functions. Ever more precise surgery is possible. Surgical workstations remove the surgeon from the immediate operative field and reduce operator fatigue by improving ergonomics. The operating team can be more completely protected from contagious or communicable diseases.</p><p>These information technologies are currently available or “just over the horizon.” To progress to the next level of minimally invasive surgery, it is necessary to recognize the merits of information technologies, embrace them, and develop practical applications for their use. The choice for their advocacy and for their use lies with us.</p></body><back><ref-list><title>References:</title><ref id="B1"><label>1.</label><mixed-citation publication-type="journal"><person-group person-group-type="author"><name><surname>Schurr</surname><given-names>MO</given-names></name><name><surname>Buess</surname><given-names>G</given-names></name><name><surname>Neisius</surname><given-names>B</given-names></name><name><surname>Voges</surname><given-names>U</given-names></name></person-group><article-title>Robotics and telemanipulation technologies for endoscopic surgery</article-title>. <source>Surg Endosc</source>. <year>2000</year>;<volume>14</volume>:<fpage>375</fpage>–<lpage>381</lpage><pub-id pub-id-type="pmid">10790559</pub-id></mixed-citation></ref><ref id="B2"><label>2.</label><mixed-citation publication-type="journal"><person-group person-group-type="author"><name><surname>Satava</surname><given-names>RM</given-names></name><name><surname>Jones</surname><given-names>SB</given-names></name></person-group><article-title>Laparoscopic surgery. Transition to the future</article-title>. <source>Urol Clin North Am</source>. <year>1998</year>;<volume>25</volume>:<fpage>93</fpage>–<lpage>102</lpage><pub-id pub-id-type="pmid">9529540</pub-id></mixed-citation></ref><ref id="B3"><label>3.</label><mixed-citation publication-type="journal"><person-group person-group-type="author"><name><surname>Sackier</surname><given-names>JM</given-names></name><name><surname>Wang</surname><given-names>Y</given-names></name></person-group><article-title>Robotically assisted laparoscopic surgery</article-title>. <source>Surg Endosc</source>. <year>1994</year>;<volume>8</volume>:<fpage>63</fpage>–<lpage>66</lpage><pub-id pub-id-type="pmid">8153867</pub-id></mixed-citation></ref><ref id="B4"><label>4.</label><mixed-citation publication-type="journal"><person-group person-group-type="author"><name><surname>Schneider</surname><given-names>I</given-names></name></person-group><article-title>Robotic tool enhances laparoscopic procedures</article-title>. <source>Medical Laser Report</source>. <year>2000</year>;<volume>14</volume>:<fpage>5</fpage>–<lpage>6</lpage></mixed-citation></ref></ref-list></back></pmc></record>Pour manipuler ce document sous Unix (Dilib)
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