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Robotics in ent
- 1. Robotics in ENT Presenter:Dr Avinav Gupta Moderator: Dr Abhinav Agarwal Consultant: Dr P K Rathore SIR
- 2. Definition Robotic surgery impliesthe use of power device that functions under Programmable computerized control and may be used to manipulate instruments and to perform surgical task
- 3. History of MedicalRobots • 1985 PUMA 560 > Steriotactic brain biopsy • 1988 PORBOT > transuretheral resection of prostate • 1992 ROBODOC > total hip arthroplasty • 1995 da Vinci Surgical System • 1998 ZEUS > gastrointestinal, cardiac and urological cases
- 4. 2002, Terris andHaus -> explored endoscopic neck procedures. 1st human application McLeod and Melder (2005) - excision of a vallecular cyst with the robot.
- 5. • Weinstein etal. described the new procedure TORS radical tonsillectomy in their first series of 27 patients with tonsillar squamous cell carcinoma. • TORS allows excellent access for resection of carcinoma of the tonsil Intraoperative photos of TORS radical tonsillectomy for T1 squamous cell carcinoma of the tonsil. (A) Tumor arising from the right tonsil; (B) Dissection in the parapharyngeal space fat; (C) Postoperative defect left to heal by secondary intention
- 6. ACCORDING TO THEROLE-BASED CLASSIFICATION 1. Active Robot 2. Semi active Robot 3. Passive Robot CLASSIFICATION OF ROBOTIC SURGICAL SYSTEMS 1. Supervisory-controlled systems 2. Telesurgical system 3. Shared-control system
- 7. SUPERVISORY-CONTROLLEDSYSTEM • Most automatedtype • System follows a specific set of instructions. • Surgeon input data into robot. Three step process: a. Planning- Determine the surgical pathway b. Registration- Surgeon finds the points on the patient body c. Navigation- Surgeon activates the robot
- 8. TELESURGICAL SYSTEMS • Surgeondirect the motion of the robot. 3 main types- • Da Vinci Surgical System • ZEUS robotic Surgical System • AESOP robotic Surgical System
- 9. SHARED-CONTROL SYSTEM • Shared-controlrobotic systems aid surgeons during surgery, but the human does most of the work -> Active constraint • The robotic system monitors the surgeon's performance and provides stability and support
- 11. Specific surgical roboticsystem • AESOP(Automated system optimal positioning) • Released 1994 • First robot clearance • Single surgical arm for voice- activated camera positioning
- 12. • Neuromate (Integrated surgicalsystems) • Neurosurgical robots used to place probes, electrodes and drills under stereotactic guidance into the brain
- 13. • The ZEUSSurgical System(computer motion, CA) is made up of an ergonomic surgeon control console and three table-mounted robotic arms, which perform surgical tasks and provide visualization during endoscopic surgery. • Voice activated.
- 14. • Da VinciSurgical System(Intuitive Surgical, CA) is currently the most widely used surgical robot.
- 15. INITIAL ROBOTIC APPLICATIONSIN OTOLARYNGOLOGY • The da Vinci robot is currently the only widely available surgical robotic system in use. • It has four components: -Surgeon console - Vision system - Endowrist instruments - Patient side cart with four robotic arms Operating room setup for TORS
- 16. • To operateThe Da Vinci surgical system • Surgeon sits at a console viewing a high definition 3D image inside the patient's body • The console is fitted with a glove like Apparatus that translates the surgeon's hand and finger movements into real time movements of the surgical instruments Operating room setup for TORS
- 17. • Patient sidecart - next to the patient - four robotic arm • One arm holding the camera • The Other arms holding the instruments
- 18. • Dual mountedendoscope provide distinct views to the right and left eyes - 3D vision to the surgeon at the console • 0 degree & 30 degree , 12mm or 8mm dia
- 19. Range of instrumentsmounted to the robotic arm can be used to perform any surgical manoeuvre: • Clamping • cutting • suturing • ligating • tissue dissection
- 20. Each instrument hasseven degrees of freedom • 3 translational (up and down, left and right, forward and backward) • Three rotational (roll, yaw and pitch) • One grip (cutting, grasping etc) • The tip of each instrument allows 90 degree of articulation
- 21. ZEUS • Position ofbed can be altered, all robot arm remain in constant location • 3arms • Voice controlled camera • 5 degree of freedom • Surgeons console- open DA VINCI • Once the robot arms are docked, bed position cannot be manipulated • 4arms • No voice activation • 7 degree of freedom • Surgeons console- closed
- 22. Additional benefit ofThe da Vinci surgical system • Motion scaling and tremor reduction • Passive Robotic Technology (robotic arms replicate precisely -movement of the surgeon's hands)
- 23. Advantages of roboticsurgery over traditional laparoscopic surgery • Improved 3D visualisation • Greater accuracy • Improved dexterity with wristed instruments • Better ergonomic for the surgeon
- 24. Advantages of roboticsurgery • Tremor control and motion scaling • Image guidance and stereotactic orientation • Binocular endoscopic vision • Telepresence and telemonitoring • Other factors
- 25. Disadvantages • Expenses • Size-instrument size is not small • Loss of force feedback/haptics- • Spacious OR • Training and learning curve • Question of saftey
- 26. Clinical application • Tonguebase tumors • OSA • Tonsils- SCC • OPSCC • Thyroid surgeries • Parotid surgeries • Otology • Skull base
- 27. RESECT TONGUE TUMOURS 1.Binocular magnification -Clearer visualization of tumor boundries -Vascular tissue -Aids accurate assessment of tumour margins. Suture through tongue and tooth guard in place
- 28. 2. ‘Wristed’ 3Dmobile grasping and cutting instruments 3. ‘Robotic surgeon’ - grasp, cut, ligate and suction in the field simultaneously. Dingman retractor setup with suction tongue blade
- 29. TORS view ofbase of tongue squamous cell carcinoma. 1. Base of tongue; 2. Base of tongue SCC; 3. 5-mm Maryland dissection forceps; 4. Left Tonsillar fossa; 5. Uvula. 6. 5-mm monopolar cautery.
- 30. OBSTRUCTIVE SLEEP APNEA •Tongue base hypertrophy- morbidity associated with open surgery • TORS • minimally invasive • Improved efficacy • minimal morbidity
- 32. (a) is theview following transoral robotic en bloc resection of a T2 tonsil cancer. (b) is the specimen with the cancer in the middle and demonstrates adequate macroscopic margins. (c) shows a fully healed lateral oropharygectomy defect. • Robotic assisted radical tonsillectomy: Mainly for Squamous carcinoma of tonsil (T1 and T2) • OPSCC
- 33. Thyroid Surgery • Smallercervical incisions • Minimally invasive video-assisted thyroidectomy technique • incision as small as 1.5 cm. • Developed noncervical incisions • Endoscopic transaxillary surgeries • -Disadv:- Technically difficult • time intensive (3 to 4 hours to perform a lobectomy).
- 34. 2005, robotic axillary thyroidectomy - insufflation based technique. 2009,gasless robot-assisted transaxillary surgery (RATS) - fixed retractor system to maintain the operative pocket Room setup for transaxillary robotic assisted thyroidectomy
- 35. Exposure for transaxialrobotic-assisted thyroid surgery. 1. Incision; 2. Sternal notch; 3. Thyroid cartilage; 4. SCM; 5. Clavicle; 6. Grounding leads for recurrent laryngeal nerve monitoring. Left-side transaxial incision. 1. Facelift retractor ; 2. Subcutaneous fat; 3. Pectoralis; 4. Left axial incision.
- 36. Selection criteria forrobotic assisted thyroidectomy Patient factors • Highly motivated to avoid cervical scar • No morbid obesity • No prior neck surgery • ASA class 1 or 2 Disease factors • Unilateral surgery • Largest nodule ≤4 cm • No thyroiditis • No pathologic lymphadenopathy • No substernal extension
- 37. Complications of RATS •Brachial plexopathies • Tracheal and esophageal injuries • Bleeding • Unacceptable rate of recurrent laryngeal nerve injury.
- 38. The robotic faceliftapproach • Postauricular skin crease- extension to the occipital hairline Dissection- direction of the sternocleidomastoid Robotic facelift thyroidectomy: Incision
- 39. Advantage of Roboticfacelift thyroidectomy over RATS: • No brachial plexopathy • Shorter length of dissection • Ability to stimulate the recurrent laryngeal nerve • Obese patients Positioning of robotic arms
- 40. Disadvantages of RoboticFacelift • Transient periauricular hyosthesia
- 41. Rhinology • Sphenoid &Ethmoid sinus surgery - Complication:- - Intracranial damage - Blindness - Death - Robot, A73 - Limited in case of sinus surgery
- 42. OTOLOGY • Application ofrobotic surgery reported - Mastoidectomy - Stapes footplate micropick fenestration by Johns Hopkins SH robot - Cochlear implant well drilling by RX130 Robot
- 43. Skull base surgery •O'Malley et al excised a high parapharyngeal space mass with a surgical robot in 2007. - Descriptions of clinical applications- absent. - Current robotic technology ?? - Fine instruments and drills- not available - Future innovations.
- 44. CONCLUSION • Continued toevolve • Transoral and thyroid procedures • Debatable : medical complications, economic, and ethical issue.
- 45.
Editor's Notes
- #5 • The first otolaryngologic application of robotics occurred in 2002, with several reports from Terris and Haus -> explored endoscopic neck procedures. • The first human application was described by McLeod and Melder in 2005 with a case report documenting the excision of a vallecular cyst with the robot.
- #15 The FDA has cleared the da Vinci Surgical System for use in urological procedures, general laparoscopic procedures, gynecological laparoscopic procedures, general thoracoscopic surgical procedures, thoracoscopically assisted cardiotomy procedures.
- #16 the daVinci ® Surgical System (Intuitive Surgical Inc., Sunnyvale, CA) is the most popular plat- form for robotic surgery. It consists of three parts: a ‘patient-side’ cart deploys surgical instruments placed by the surgeon within the patient’s body including a bin- ocular 12 mm endoscope with dual zero or thirty degree optics, and a ‘surgeon’s console’ which is remotely placed where three-dimensional surgical anatomy is recreated and linked to instruments in a virtual environment. The surgeon’s console consists of a three-dimensional display, a seat for the surgeon, foot pedals to control cautery and other instruments, and hand controls linked to instru- ments placed in the operative feld. The three-dimensional display affords the surgeon unprecedented perspective and visualization of surgical anatomy along with the ability to operate with 540 degrees of wristed instrumentation at zero or thirty degree angles. Motion scaling increases pre- cision by eliminating tremor and fatigue while also reduc- ing greater hand movements. The ‘vision cart’ houses the video processor and screens to project the procedure, primarily used by the operating assistant and the other observers.
- #17 To operate The Da Vinci surgical system Surgeon sits at a console viewing a high definition 3D image inside the patient's body The console is fitted with a glove like Apparatus that translates the surgeon's hand and finger movements into real time movements of the surgical instruments
- #19 The camera uses dual mounted endoscope that provide distinct views to the right and left eyes which produce a truly 3D field of vision for the surgeon at the console Both 0 degree and 30 degree endoscope with either 12mm or 8mm diameter are available
- #23 Motion scaling and tremor reduction- large movement by the surgeon are translated into find moments of robotic instruments without tremor This system utilizes passive robotic Technology such that the movement of instruments attached to the robotic arms replicate precisely the movement of the surgeon's hands
- #25 Instrument stabilization tremor control and motion scaling Image guidance and stereotactic orientation of the surgical instrument Binocular endoscopic vision Open and microscopic procedure do not allow binocular vision Endoscopic and laparoscopic- loss of 3D vision and depth perception Telepresence and telemonitoring
- #26 Expenses: zeus and da vinci cost around $1.12 – 1.16 million Size- instrument size is not small Currently available size 8 mm and 10 mm diameter instrument Loss of force feedback/haptics- loss of tactile perception Spacious OR
- #27 With the initial success of robotic surgery in otolaryngology, it has been most intensively evaluated for the management of pharyngeal laryngeal thyroid and skull base diseases
- #28 Da Vinci Transoral comparis to standard trans oral resectionthere are three benefits:- Binocular magnification at the surface of the resection allows: -clearer visualization of tumor boundries -vascular tissue -aids accurate assessment of tumour margins.
- #29 2. The use of 'wristed' three-dimensionally mobile grasping and cutting instruments allows better resection of the tumour compared with direct transoral view. This improves the accuracy of tumour resection and manipulation of the specimen and vessels, making the surgery easier to perform. 3. The 'robotic surgeon' operating through two hand controls allows the 'manual assistant' to grasp, cut, ligate and suction in the field simultaneously. It would be very difficult for a standard transoral procedure to take place with four surgeons' hands working on the tongue base.
- #31 20 million adults in the United States suffer from OSA The role of tongue base hypertrophy have either been ineffective or they carry the morbidity associated with open surgery. TORS can potentially address the role of tongue base hypertrophy in OSA in minimally invasive fashion with improved efficacy and minimal morbidity.
- #34 Earlier minimally invasive approaches- use of smaller cervical incisions in thyroid surgery. Later, minimally invasive video-assisted thyroidectomy technique, -This technique can be performed through an incision as small as 1.5 cm. -Developed noncervical incisions-removal of the thyroid gland (endoscopically) Endoscopic transaxillary surgeries were performed. -Disadv:- Technically difficult time intensive (3 to 4 hours to perform a lobectomy). Then concept of merging robotic technology with a totally endoscopic thyroid procedure
- #35 In 2005, the first successful robotic axillary thyroidectomy was reported as an insufflation based technique. In 2009, gasless robot-assisted transaxillary surgery (RATS) that uses a fixed retractor system to maintain the operative pocket, thus eliminating the need for gas insufflation
- #39 -Facelift-type incision is used to approach the thyroid compartment from the postauricular skin crease with extension to the occipital hairline, and a fixed retractor system maintains the exposure during the procedure. -The dissection is then carried along in the direction of the sternocleidomastoid
- #40 No risk of brachial plexopathy -position. Shorter length of dissection Ability to stimulate the recurrent laryngeal nerve Perform the procedure in slightly obese patients due to the ease of raising the skin flaps.
- #41 Transient periauricular hyosthesia : greater auricular nerve
- #42 Done for Sphenoid & Ethmoid sinus surgery Complication:- Intracranial damage Blindness Death Robot, A73 by research team & includes drill, suction, irrigation. Robotic surgery is limited in case of sinus surgery
- #44 O'Malley et al excised a high parapharyngeal space mass with a surgical robot in 2007. more recent descriptions of clinical applications have been absent. This likely reflects the fact that current robotic technology does not fully meet the needs of skull base surgery; the fine instruments and drills required for these operations are not yet available. However, with further instrument and robotic development, the skull base likely represents a rich environment for future innovations.
- #45 The application of surgical robotics in otolaryngology has continued to evolve since the first report in 2002. Transoral and thyroid procedures are now regularly performed, and new uses are emerging. The debate over the proper role of the robot continues, and robotic technology remains a complicated medical, economic, and ethical issue.