Laparoscopy, also called Minimally Invasive Surgery (MIS) or keyhole surgery is a revolutionary procedure that has improved the quality of life of patients. The procedure is done with a laparoscope which consists of a video camera and specific thin instruments. In the operating room, the laparoscope is maneuvered by a camera assistant according to instructions from the surgeon. Its demand has grown over the years due to major advantages such as faster wound healing, less morbidity, less discomfort, quicker recovery time, and better outcomes. Many advancements both in procedure and in the instruments used have occurred in recent decades.
Unlike traditional open surgery, laparoscopy only requires upto 3 small incisions in the abdomen of the patient to do the procedure. Apart from a laparoscope, tools such as slide lock graspers, axial needle holders, forceps, scissors, probes, dissectors, hooks, and retractors are also used. The more recent laparoscopes come with 3D high-definition vision that helps to sense depth which is required while performing MIS. The person holding the laparoscope may experience fatigue and lead to a “Camera shake”. This can cause the surgeon to lose orientation, especially when using 3D vision. Therefore, a laparoscope holder is an important and effective advancement for performing laparoscopic surgery.
Robots can help enhance laparoscopic surgery and are classified into the master-slave type and hand-held forceps. The master-slave type has a 6-degrees-of-freedom (DOF) of motion. The robot has a 4-DOF arm outside the abdominal cavity and a 2-DOF wrist joint at the forceps tip. The forceps tip can approach the target in the abdomen from an arbitrary position and posture. The surgeon operates the remote slave arms with the wrist joint via the master console. The robot enables an intuitive operation since the slave arms in the abdomen reproduce the surgeon’s 6-DOF hand motion at the console. In addition, robots enable telesurgery via network and microsurgery by changing the motion scale between the master and the slave.
In 2000, Robotic-Assisted Surgery (RAS) for general laparoscopic surgery was first introduced through the da Vinci Surgery System, the most famous robotic surgical system which was approved by the US Food and Drug Administration (FDA). The da Vinci Surgical System has four interactive robot arms – one for camera control, three for manipulating instruments – which are operated by the surgeon from the surgeon’s console. These arms can have a combination of different tools that can either grasp, cut, and cauterize. The most recent version, the da Vinci Xi has a magnified 3D HD vision, EndoWrist instrumentation & intuitive motion, and enhanced ergonomics.
There are some disadvantages to using the master-slave type of robot. It requires space for the master console and has a high introduction and operating costs. Hence, hand-held robotic forceps were developed. The forceps have a wrist joint at its tip and are manipulated from the interface mounted on the forceps. Its setup time is shorter than the master-slave robot and is easier to handle due to the smaller size.
The hand-held forceps can be divided into those controlled by actuators and those manipulated mechanically. Many hand-held forceps have been developed based on modes and functionalities such as driven by electric motors, lightweight forceps with separate actuators, thin diameter robotic forceps, and based on ergonomics. Other improvements in hand-assisted surgical instruments feature articulating end-effectors for easier movement. In 2011, a team of undergraduate researchers from De La Salle University, Philippines developed a laparoscopic instrument that achieved 4 DOF. FlexDex Inc, a laparoscopic device platform company, has developed a similar device that uses technology to precisely translate the surgeon’s hand, wrist, and arm movements without any electronic component.
Combining robotic surgery with augmented reality to increase safety and deal with difficulties associated with minimally invasive approaches is being studied extensively. Augmented reality superimposes virtual objects on the laparoscopic image enhances the safety and efficiency of surgery. Surgeon’s fatigue can be reduced by automation and autonomous and semi-autonomous systems are already in place for several surgical procedures.
Surgical robotics can improve the surgical experience with the combination of robots and artificial intelligence. The next generation of surgical robots will aim to make surgery less expensive, evidence-based, easier, and safer. Surgical robots effectively augment a surgeon’s skills to achieve accuracy and high precision during complex procedures thus helping to improve a patient’s quality of life.