Advances in Laparoscopic Surgery
As opposed to open surgery, which is done through larger incisions, laparoscopic surgery is abdominal or pelvic surgery performed by placing a scope and operating instruments through tiny incisions in the patient. Laparoscopic surgery represents a huge advance over open surgery, allowing faster recovery and shorter hospitalization for patients and conventional laparoscopic surgery is the standard of care for many surgeries nowadays. However, it has its limitations. Robotic surgery represents an evolution in laparoscopic surgery.
Traditional laparoscopic surgery
With conventional laparoscopy, carbon dioxide gas is used to inflate the abdominal cavity, creating a working space allowing the surgeon to be able to see. Small plastic or metal tubes, called ports, are then placed through the abdominal wall into the abdominal cavity. The laparoscope is placed through one of these tubes and, using a camera as an interface, allows visualization of the inside of the patient by looking at a monitor. Looking through a monitor provides no depth perception, although skilled laparoscopic surgeons accommodate with skill and practice.
The laparoscopic instruments are then placed through the ports in order to perform the surgery. These are long skinny sticks with relatively simple instruments at the tip. They open, close, and rotate and are used to grasp or cut tissue depending on the instrument. These simple instruments with limited movement and no articulation make it very difficult to perform surgery in very small spaces, like the bottom of the pelvis. All movements are backward; the abdominal wall is a fulcrum so to move an instrument to the left inside the patient, the surgeon has to move to the right outside the patient, which is where the surgeon controls the instruments. The laparoscopic instruments make it harder to perform complex tasks, such as suturing. In addition, no matter how steady a surgeon is, there is always some element of a tremor which is amplified at the end of the laparoscopic instrument.
Robotic surgery differs from conventional laparoscopic surgery in that there is a robotic interface between the surgeon and the laparoscopic instruments and scope. The robotic instruments are the same long sticks used in laparoscopic surgery, but the instruments not only open, close, and rotate, but also articulate just like a human wrist. The movements are more intuitive; to move the instrument left, the surgeon moves to the left. Any tremor is subtracted by the robotic computer making the instruments perfectly steady. Finally, the scope placed through a small plastic tube has two lenses and two cameras, each feeding one eye of the surgeon. This provides three-dimensional vision and is far superior to the two-dimensional view with no depth perception surgeons have with conventional laparoscopic surgery. The surgeon sits at a console, looking down towards his or her hands through a pair of binoculars. However, instead of seeing hands, the surgeon sees the instruments inside of the patient. Every movement at the console is duplicated precisely by the robot inside of the patient. This makes complex surgery in small spaces, particularly those with a lot of suturing, much easier and safer than conventional laparoscopic surgery. The effect is that the surgeon has become a tiny person inside of the patient. The robot is not performing the surgery. The surgeon is performing the surgery with a robotic interface.
Some oppose robotic surgery and claim that it is too expensive and unnecessary; anything that is done robotically can be done with conventional laparoscopy. While this is true for some surgeries, more complicated surgeries such as prostate removal or partial kidney removal for cancer can now be done robotically, making the surgery available to all patients by surgeons who have access to a robot.
What does all of this mean?
Robotic surgery patients don’t recover faster than laparoscopic patients. However, robotic surgery expands the indications for laparoscopic surgery allowing almost any surgery, that used to be performed through an open incision, to be done endoscopically. Overall, this results in shorter hospital stay, faster recovery, less blood loss, and (for some surgeries) better cancer control.
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