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  • 1. VITREORETINAL SURGERY FEATURE STORY Robotic Surgery in Ophthalmology The use of a robotic surgical system can provide added dexterity for delicate intraocular manipulations. BY JEAN PIERRE HUBSCHMAN, MD; ANGELO TSIRBAS, MD; AND STEVEN D. SCHWARTZ, MDI nnovations in ophthalmology have expanded greatly in view of the operative field from the endoscope (Figure 3). recent years, and we believe that the next major The surgeon manipulates the controls using fingers, wrists, advancement in ophthalmology will be the integration hands, and arms, while a computer processor filters, scales, of robotic surgery. Robotic systems have been utilized in and relays the movements to the robotic arms and instru-the surgical environment for more than 15 years. Since then, ments (Figure 4). There is no measurable delay between therobotic surgical systems have proliferated1 in several disci- movement of the surgeon’s controls and the mirroredplines such as urologic surgery,2-5 gynecologic surgery,6,7 and movement of the robot apparatus. The processor eliminatescardiovascular surgery.8-10 Multiple robotic surgical systems tremors and minor movements. The architecture of thehave been developed over the years, and the current stan- instruments and the da Vinci system allows the surgeon todard is the da Vinci Surgical System (Intuitive Surgical, insert, extract, roll, pitch, yaw, and grip with the roboticSunnyvale, CA).11 tools. The robotic arms are capable of tilt in two planes, achieved with two “elbow” joints. The robotic arms can beROBOTIC SURGICAL SYSTEM equipped with a variety of instrumentation to allow for spe- The da Vinci Surgical System consists of two primary cialized surgical procedures. Robotic surgery addresses somecomponents, a control console that allows the surgeon to of the limitations of traditional surgery, allowing the com-manipulate the robotic arms remotely (Figure 1), and the pletion of advanced procedures. Advantages of robotic sur-robotic apparatus with three arms (or four arms in a recent gery include increased precision, improved range of motion,addition) that holds a dual-channel endoscope (Figure 2). elimination of tremor, ability to maneuver in small anatomicAn ocular viewfinder on the console provides a stereoscopic spaces, and surgeon safety.12-16Figure 1. The surgeon sits comfortably at the surgical con- Figure 2. The da Vinci robotic system has three arms. Onesole, having a 3-D view of the surgical field and easy access to central arm holds the endoscope, and two side arms (greenthe control handles. and yellow stripes) hold surgical instruments. MAY/JUNE 2008 I RETINA TODAY I 81
  • 2. VITREORETINAL SURGERY FEATURE STORY Figure 3. View through the console’s view-finder. Figure 4. Focused view of the robotic console’s joystick. INSTITUTE AND GLOBAL EXPERIENCE by manipulation of the robotic arms. Healon GV Recently, the feasibility and applicability of robotic ocular (Advanced Medical Optics, Santa Ana, CA) was intro- surgery were analyzed through a series of pioneering duced into the anterior chamber, and a 5.0x2.5x 0.2-mm studies.17-19 First-time demonstrations of external ocular sur- copper strip (Rogers Corporation, Chandler, AZ) was gery (corneal and scleral wounds), anterior segment surgery placed over the lens by a human assistant. The intraocular (foreign body removal and capsulorrhexis), and posterior forceps linked to the robotic arm were used to grasp and segment surgery (25-gauge vitrectomy) while utilizing the remove the metallic foreign body from the anterior cham- da Vinci surgical robot have been performed at the Center ber. Healon GV was injected by the assistant to deepen for Advanced Surgical and Interventional Technology at the the chamber, and a cystotome held by the robotic forceps University of California, Los Angeles. All the experiments was used to fashion a 360º capsulorrhexis via movement were performed on harvested porcine eyes secured with of the robotic arms. pins on a Styrofoam mannequin head in the anatomic posi- Twenty-five–gauge robotic vitrectomy was performed tion. The head was placed on a surgical table positioned after adaptation of the commercially available intraocular directly under the robotic apparatus. The initial step was to instruments for use with the robotic forceps. To allow manually inflate the eye with balanced salt solution to reach gripping with the robotic tools, small metal plates were good intraocular pressure. fixed to the handles of a 25-gauge vitreous cutter and Visualization of the eye was achieved with the 3-D endo- endoilluminator (Alcon Surgical, Fort Worth, TX). The scope placed above the globe in the midline, thus mimick- instruments were held by a magnetic stand to facilitate ing the axis of standard ocular surgery using an operating easy grasping and storage (Figure 5). Intraocular forceps microscope. The robotic arms were placed on either side of were fitted with a custom bracket to facilitate operation the globe at approximately 45° angles, resembling the with the robotic arm and wrist (Figure 6). approach used by an operating surgeon. The surgical con- sole was located approximately 15 feet from the surgical table and robotic arms. Viewing the operative field via a 3-D image and placing the hands on the master controls below the display, the surgeon was seated comfortably. All proce- dures were performed by an experienced retinal surgeon with no prior practice in robotic surgery. SURGICAL PROCEDURE Robotic external ocular surgery was performed with robotic arms each equipped with sterile Black Diamond microforceps (Intuitive Surgical). Several 10-0 nylon fila- ment sutures were placed to close each corneal and scler- al wound. To evaluate the feasibility of anterior-segment Figure 5. Metal plates were fixed to the 25-gauge instru- robotic surgery, the tip of a 3-mm keratome held by the ments. The instruments were held with a magnetic stand to robotic forceps was used to create a clear corneal incision ease grasping and storage during surgery.82 I RETINA TODAY I MAY/JUNE 2008
  • 3. VITREORETINAL SURGERY FEATURE STORYFigure 6. Intraocular forceps fitted with a custom bracket to Figure 7. Setting of the infusion cannula with the roboticfacilitate operation with the robotic arm and wrist. forceps. Using the robotic forceps, a 25-gauge infusion trocar tion of the forceps would facilitate more delicate maneuvers(Alcon Surgical) was placed approximately 3 mm posterior and enhance grasping of smaller the limbus in the inferotemporal quadrant. An infusion Control and manipulation of the ocular surgical instru-cannula was placed in the trocar with the robotic forceps ments was performed with relative ease by moving the tipand turned on by an assistant (Figure 7). Two additional tro- of the robotic forceps. For example, insertion of the instru-cars were placed in a similar fashion approximately 3 mm ments into the globe and minute adjustments during theback from the limbus in the superotemporal and nasal vitrectomy were relatively easy tasks. Application of the tro-quadrants. A disposable wide-view vitrectomy contact lens cars and insertion of the vitreous cutter and endoillumina-(Dutch Ophthalmic USA, Kingston, NH) was placed on the tor through the 25-gauge ports were smooth and swift.cornea with viscoelastic. The vitreous cutter and endoillumi- Anterior capsular manipulations, however, were less accu-nator were grasped from the magnetic stand with the rate, and a round curvilinear capsulorrhexis was notrobotic forceps and placed through the 25-gauge trocars achieved. The surgeon’s wrist movements translated almostusing the robotic arms (Figure 8). Under high-magnification intuitively to instrument manipulation with no notable diffi-view, a core vitrectomy was performed. At the end of the culties, despite lack of prior experience with the robot.vitrectomy, the instruments were placed on the magnetic We observed that arm movements were not as intu-stand and the trocars removed from the eye with the robot- itive as wrist movements. Capable of two-plane tilt with-ic forceps. All the vitrectomy procedures were performed out joint rotation, the robotic arms do not mirror thewith the Accurus 800CS (Alcon Surgical) fitted with a xenon exact movements of human arms. Indeed, this robot waslight source.POST-SURGICAL OBSERVATIONS Several observations were noted at the conclusion of thisstudy. First, visualization was a challenging aspect that willrequire refinement. While the resolution of the dual-channelendoscope’s camera was of high quality and provided excel-lent depth perception for the external and anterior segmentsteps of the ocular surgery, it did not yield the detail of anoptical microscope routinely used in intraocular surgery.Also, the camera realignment was frequent and time-consuming. For instance, each time an ocular instrumentwas fetched from the magnetic stand, the endoscope hadto be tilted and zoomed out to facilitate adequate view.Lack of an optical inversion system prevented the use ofstandard wide-angle vitrectomy lenses. Figure 8. Insertion of the modified 25-gauge vitreous cutter Currently, the microforceps are tailored toward place- and endoilluminator with the robotic arms. Left corner: lowment of 7-0 sutures in cardiac surgery. Further miniaturiza- magnification view from the robot’s endoscope. MAY/JUNE 2008 I RETINA TODAY I 83
  • 4. VITREORETINAL SURGERY FEATURE STORY emergency eye care to sites such as the battlefield or envi- ronments with limited accessibility. ■ Jean Pierre Hubschman, MD, is Clinical Instructor of Ophthalmology at the Jules Stein Eye Institute in Los Angeles. He has no financial relationships to dis- close. Dr. Hubschman can be reached at: +1 310 206-5004; fax:+1 310 794 7905; or Figure 9. Visualization of the stable point of rotation (remote Angelo Tsirbas, MD, is Clinical Instructor of center). Oculoplastics at the Jules Stein Eye Institute. He has no financial relationships to disclose. Dr. originally designed for laparoscopic surgery and subse- Tsirbas can be reached at: +1 310 206 8250; fax: quently was given a high (above the wrist) remote center +1 310 825 9263; or to avoid inadvertent tension on the skin opening during Steven D. Schwartz, MD, is Ahmanson Professor of surgery (Figure 9). This configuration was counterpro- Ophthalmology, Associate Professor of ductive and represented the main limitation when per- Ophthalmology, Chief of the Retina Division, forming intraocular surgery, in which a low stable point Director of the Diabetic Eye Disease and Retinal of rotation is desired at the site of ocular penetration Vascular Center, and Director of the Ophthalmic (below the wrist) to avoid inadvertent tension on the Photography Clinical Laboratory at the Jules Stein external eye surface. Tilting of the robotic elbow joints Eye Institute. He is also a member of the Retina Today resulted in unintended translation at the tips of the ocu- Editorial Board.He has no financial relationships to disclose. Dr. lar instruments. Maneuverability of the instruments was Schwartz can be reached by phone: +1 310 206 7474; fax: +1 also limited, as the endoscope prevented positioning of 310 825 3350; or the robotic arms vertically. This limitation posed a prob- 1. Buckingham RA, Buckingham RO. Robots in operating theatres. BMJ 1995;311:1479–1482. lem during vitrectomy, rendering the outer vitreous gel 2. Ruurda JP, Broeders IAMJ, Simmermacher RPM et al. Feasibility of robot-assisted laparoscopic sur- approachable only with contralateral instruments. gery. Surg Laparosc Endosc Percutan Tech. 2002;12:41–45. 3. Kumar R, Hemal AK Emerging role of robotics in urology. J Min Access Surg. 2005;1:202–210. 4. Dasgupta P, Challacombe B, Murphy D, et al. Coming full circle in robotic urology. BJU Int. CONCLUSION 2006;98:4–5. 5. Kaul S, Laungani R, Sarle R, et al. da Vinci-assisted robotic partial nephrectomy: technique and As this study demonstrated, the da Vinci robotic sys- results at a mean of 15 months of follow-up. Eur Urol. 2006;51:186–191. 6. Diaz-Arrastia C, Jurnalov C, Gomez G, Townsend Jr C. Laparoscopic hysterectomy using a com- tem provided the needed dexterity for delicate intraocu- puter-enhanced surgical robot. Surg Endosc. 2002;16:1271–1273. lar manipulations. The da Vinci Surgical System in its cur- 7. Beste TM, Nelson KH, Daucher JA. Total laparoscopic hysterectomy utilizing a robotic surgical sys- tem. J Soc Laparoendosc Surg. 2005;9:13–15. rent design, however, presents two limitations for intraoc- 8. Katz MR, Van Praet F, de Canniere D et al. Integrated coronary revascularization: percutaneous coro- ular surgery. First, having a stable point of rotation above nary intervention plus robotic totally endoscopic coronary artery bypass. Circulation. 2006;114:473–476. the robotic wrist renders intraocular maneuvers less con- 9. McClure RS, Kiaii B, Novick RJ, et al. Computer-enhanced telemanipulation in mitral valve repair: preliminary experience in Canada with the da Vinci robotic system. Can J Surg. 2006;49:193–196. trollable. Second, the endoscope-acquired images are infe- 10. Kypson AP, Chitwood WR. Robotic cardiovascular surgery. Expert Rev Med Devices. rior to those obtained with an ophthalmic microscope, as 2006;3:335–343. 11. Labontiu A. The da Vinci surgical system performing computer-enhanced surgery. Osp Ital Chir. its dynamic range, optical resolution, and color presenta- 2001;7:367–372. tion do not match the abilities of the human eye. 12. Hashizume M, Konishi K, Tsutsumi N, et al. A new era of robotic surgery assisted by a computer- enhanced surgical system. Surgery. 2002;131:S330–S333 It is reasonable to assume that opportunities for robotics 13. Prasad SM, Prasad SM, Maniar HS, et al. Surgical robotics: impact of motion scaling on task per- formance. J Am Coll Surg. 2004;199:863–868 in ophthalmic surgery lie in performing interventions 14. Hernandez JD, Bann SD and Munz Y, et al. Qualitative and quantitative analysis of the learning curve which only the robotic system renders possible, or which of a simulated surgical task on the da Vinci system. Surg Endosc. 18:372–378. 15. Moorthy K, Munz Y, Dosis A, et al. Dexterity enhancement with robotic surgery. Surg Endosc. noticeably simplify the current approach. Surgical proce- 2004;18:790–795. dures that demand perfect stability and high degrees of 17. Gomez-Blanco M, Riviere CN, Khosla PK. Intraoperative tremor monitoring for vitreoretinal micro- surgery. Stud Health Technol Inform. 2000;70:99–101. accuracy such as retinal vessel cannulation and intravascu- 18. Riviere CN, Jensen PS. A study of instrument motion in retinal microsurgery. Abstract presented at 21st Annual Conference of IEEE Eng Med Biol Soc; June 26, 2000; Chicago. lar drug delivery, may become more feasible as robotic 17. Tsirbas A, Mango C, Dutson E. Robotic ocular surgery. Br J Ophthalmol. 2007;91:18– 21. microsurgical manipulations can be safer with less iatro- 18. Hubschman J, Bourla D, Tsirbas A, et al. Robotic vitreoretinal surgery. Presented at the 2007 ARVO Annual Meeting; 6–10 May, 2007; Fort Lauderdale, FL. genic complications. 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