Newly advanced technology

1. By Dr Meithreya
Ro ENT

2. Definition
Robotic surgery implies the 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 Medical Robots
• 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 and Haus -> explored endoscopic neck procedures.
1st human application McLeod and Melder (2005) - excision of a
vallecular cyst with the robot.

5. • Weinstein et al. 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 THE ROLE-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 automated type
• 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
• Surgeon direct 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-control robotic 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 robotic system
• AESOP(Automated system
optimal positioning)
• Released 1994
• First robot clearance
• Single surgical arm for voice-
activated camera positioning

12. • Neuromate (Integrated
surgical systems)
• Neurosurgical robots used
to place probes, electrodes
and drills under stereotactic
guidance into the brain

13. • The ZEUS Surgical 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 Vinci Surgical System(Intuitive Surgical, CA) is currently
the most widely used surgical robot.

15. INITIAL ROBOTIC APPLICATIONS IN
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 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
Operating room setup for TORS

17. • Patient side cart -
next to the patient -
four robotic arm
• One arm holding the
camera
• The Other arms
holding the
instruments

18. • Dual mounted endoscope 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 instruments mounted to the robotic arm can be used to
perform any surgical manoeuvre:
• Clamping
• cutting
• suturing
• ligating
• tissue dissection

20. Each instrument has seven 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 of bed 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 of The 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 robotic surgery over
traditional laparoscopic surgery
• Improved 3D visualisation
• Greater accuracy
• Improved dexterity with wristed
instruments
• Better ergonomic for the surgeon

24. Advantages of robotic surgery
• 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
• Tongue base 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’ 3D mobile
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 of base 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 the view 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
• Smaller cervical 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 transaxial robotic-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 for robotic 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 facelift approach
• Postauricular skin crease- extension to the occipital hairline
Dissection- direction of the
sternocleidomastoid
Robotic facelift thyroidectomy: Incision

39. Advantage of Robotic facelift 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 Robotic Facelift
• 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 of robotic 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 to evolve
• Transoral and thyroid procedures
• Debatable : medical complications, economic, and ethical issue.

45. THANK YOU