How Robotic Surgery Advances Care for Patients

The modern version of laparoscopic, or minimally invasive surgery, first emerged in the 1980s, but in the last 30 years the medical community has experienced significant advancements in laparoscopic surgery that have improved the way we care for patients.

In 2000, the FDA approved the first robotic surgery system. In the last 17 years we’ve seen more surgeons across the country adopt this approach. While open or laparoscopic surgery still may be the best approach for some patients, depending on the case, robotic surgery may improve outcomes and may provide more options for patients who wouldn’t otherwise have them.

Understanding Robotic Surgery

Robotic surgery is less of a replacement for laparoscopic surgery and more of an evolution of laparoscopic surgery. A lot of the principles we've learned over the last 25 or 30 years that doctors have used to do laparoscopic surgery still apply. It's still a way to gain access to the abdomen to perform procedures through smaller incisions as opposed to larger ones.

But robotic surgery has several advantages. As a surgeon, it allows me to do things that I might not otherwise be able to do, particularly when it comes to visualization and control. A traditional laparoscopic camera is a two-dimensional camera. It's basically on a TV screen that is positioned on the other side of the patient from the surgeon as we operate.

One of the challenges for surgeons as they learn laparoscopy, and as you try to do more and more advanced cases, is that the view you have is in two dimensions but you must operate in three dimensions so there's some translation that has to happen. As the case becomes more complicated, it becomes more challenging and sometimes it can lend itself to the surgeon making errors based on the way his or her body or brain perceives that two-dimensional image and translates it. You think you're seeing one thing, but the reality is different. 

With a robotic system, the camera is in three dimensions. Rather than having the screen positioned across the patient, the surgeon sits at the console with his or her head in the console, and the screen is directly in front of his or her eyes. The surgeon’s operative field of vision is basically the entire field of vision with no other distractions and a three-dimensional image. It typically magnifies in a clearer way than with traditional laparoscopy, so the surgeon can see more clearly and more immersively.

The second advantage is the instrumentation itself. A traditional laparoscopic instrument is not dissimilar from a tool you’d see someone using to reach down and pick up trash from the side of the road. It's a long instrument that goes in, that can open and close and that can turn around in a circle. That's pretty much the limitation of the motion. We describe it in terms of degrees of freedom — there are fewer degrees of freedom of motion. However, robotic instruments have a wrist in the same way your arm has a wrist. It allows the tip of the instrument in a robotic case to mimic the same motion that you would make with your own wrist.

When you're doing a robotic case, your motion is the same hand motion that you use for every other case because the instrument actually has a wrist. It allows for a more natural transition from open to minimally invasive surgery and lets the surgeon perform actions he or she might not otherwise be willing to try in a minimally invasive way. Basically, it gives patients greater access to minimally invasive surgery because, from a technical standpoint, the technique limits what you could do with open surgery.

Driving Better Patient Care

Because of the advantages with the surgeon’s field of view and the instrumentation, we can basically perform a procedure exactly the way we would perform it in an open operation but through a minimally invasive incision. 

For patients, this has several benefits, including faster recovery, a shorter hospital stay, less pain and a return to their normal, everyday activities a lot sooner. It’s not entirely clear why robotic surgery produces these advantages over laparoscopic surgery, but it may have to do with the precision of the instrumentation and the natural motion it allows as the surgeon operates. 

Still, there are some misconceptions about robotic surgery that may keep patients from being open to this approach and realizing these benefits. I sometimes get asked whether the robot actually performs the surgery rather than the surgeon. To be clear, the robot never acts independently. In a way, the robot is no different than any tool I’d use a surgeon to operate laparoscopically. If I'm doing a laparoscopic case, my hand is at the end of that instrument, I control when it opens and closes and moves left and right. If I'm not doing anything, it’s not moving. The robot functions the same way. The robotic hand is on the instrument but I'm controlling it in the same way. With robotic surgery, the surgeon sits at the console and uses the controls on the console to direct the motion of the arms and the motions of the camera. If I stop moving, it stops moving. If I start moving, it moves. In fact, it moves better than I move because the motion is scaled, so I can make large motions with my hands that translate to small motions on the robot. This allows me to have more fine control than I would otherwise.

It’s also important to mention that when we do robotic surgery at Orlando Health, the doctor is in the same room as the patient. While it’s technically possible to do robotic surgery from a different room or even a different state or country, our approach is to have the surgeon in the operating room. There’s also someone by the patient’s bedside at all times, so the patient is never alone.

Overall, robotic surgery allows for more precision and control than traditional minimally invasive surgery or open surgery. On top of all this, the robot never gets tired of holding the camera, never gets distracted by other things going on in the operating room and never loses focus. In a lot of ways, that's an advantage. It allows the surgeon to be in a more ergonomic position throughout the operation, so the team and the person performing the surgery is fresh. Another key advantage is that robotic surgery opens up more treatment options for patients who would otherwise be relegated to open surgery, which has a longer recovery time and often comes with greater risk of complications.

Many skilled laparoscopic surgeons are choosing robotic surgery because it provides better care for patients. Ninety percent of the cases I do robotically also can be performed laparoscopically, but robotic surgery allows us to give better service and better care to patients. And ultimately, no matter which surgical approach you choose, that is the most important factor.