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Having been first used clinically in medicine in 1985, medical robotics is coming of age after several decades of discovery, use, and refinement.
Some of the drivers behind the trend include; less invasive treatments, access to hard-to-reach places with accuracy (ideally, involving pre-operative and or real-time imaging), increased use of intraoperative images, and improved robotics, including hepatic feedback.
Some of the potentials of medical robotics has yet to be realized, yet the procedures are now present in most medical specialties including thoracic surgery, orthopedics, emergency medicine, rehabilitation medicine, neurosurgery, and radiation oncology.
Attempting to Improve the Overall Outcome
The hope, and, what some studies have already shown, is that surgery with robot assistance can improve overall outcomes while reducing hospital stays, but long-term trend data in the desired quantity is not enough. It has been suggested that there is a need for control studies with sufficient patients involved in robotic-assisted surgeries in all fields.
Robotics could potentially enable greater levels of telemedicine, so that modern medicine can reach more people across the globe, although initially, the use of new robotic surgeries can have the effect of clustering care. An early example of this trend is the use of Intuitive Surgical’s da Vinci robotic surgery system for radical prostatectomy (RP) - operating on a man’s prostate gland through a few small incisions or the belly button from a nearby ergonomic console. With so many RPs being performed robotically, the procedures have been increasingly centralized at certain medical centers with certain physicians.
There is still a need for more technological advances, and perhaps an improved method or duration of time needed for surgeons to acquire all of the necessary skills for robotics’ widespread use. For example, laparoendoscopic single-site surgery (LESS) and natural orifice transluminal endoscopic surgery are novel techniques using often one incision, but their technical difficulty, including the need to use highly specialized instruments, means longer adoption cycles.
Positive Short-Term Results
Overall, however, data on medical robotics is showing positive shorter-term results as the following examples of evidence.
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Mitral Valve Disease
U.S. results, published in 2011, was a three-year comparison of robotic sternotomy and thoracotomy approaches to mitral valve surgery outcomes in more than 700 patients with mitral valve disease. Even though operation and ischemic times (the latter being the time when the organ is outside body or supplied with oxygen by the coronary arteries) were longer with the robotic approaches, the robotic approaches had the lowest occurrences of irregular, often rapid heart rate (atrial fibrillation) and excess fluid in the lungs (pleural effusion) and the shortest hospital stays. The overall quality of mitral valve repair was considered similar among matched groups as were the overall complication rates.
Head and Neck Surgery
Since the first cases in 2006, robotics used in head and neck surgery - generally called transoral minimally invasive approach - have decreased overall morbidity and provided excellent functional results (throat and tongue moving normally) with equivalent cancer outcomes. Robotics has enabled surgeons to access anatomical locations that were previously managed only through highly invasive techniques, but not through conventional endoscopy.
Some of the other advantages have been: the absence of a neck incision, absence or decreased duration of tracheotomy, absence or decreased duration of nasogastric or gastric feeding tubes, and decreased lengths of hospital stay.
Robot-Assisted Radical Prostatectomy
RARP (robot-assisted radical prostatectomy) has overtaken open RP as the most common surgical approach for RP, since it's FDA approval in 2001. In fact, approximately 80% of U.S. RP procedures are being performed robotically, and yet this growth has been controversial in part due to the learning curve needed to become masterful with the robotics.
Awaited study results released in 2012 revealed superior preoperative outcomes after RARP compared to open prostatectomy in virtually all outcomes. Of 19,462 RPs, 61.1% were RARPs, 38.0% were open RPs, and 0.9% were laparoscopic RPs. In multivariable analysis, patients undergoing RARP were less likely to receive a blood transfusion, experience complications, such as urinary or erectile problems, and have long lengths of stay.
These examples reflect the entrenchment of robotics in clinical medicine, and at the same time, a need for greater exploration and refinement in a rapidly developing field.
Sources and Further Reading
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