Introduction
Automated surgical instruments have grown past the testing phase and are currently routinely utilized as a part of several surgical procedures such as minimally invasive general surgery, pediatric surgery, ophthalmology, urology, neuro surgery, cardiothoracic surgery and otorhinolaryngology. Robotic instruments keep on developing and upgrading in time and – as they turn out cheaper and more generally widespread – will probably turn out to be all the more frequently used in surgical methodology. The authority of the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) and the Minimally Invasive Robotic Association (MIRA) felt that rules for the use of robots in surgery were missing, and that the surgical group would profit by a general consensus on robotic surgery including rules for training and giving credentials.
Robots and robotic procedures entered the field of urology in the late 1980s with the use of a mechanical arm named PUMA 560, for transurethral resection of the prostate (TURP) (Lanfranco et al., 2004). This early therapeutic robot was endorsed for a constrained clinical trial in people. It didn't turn into a decisive treatment method for TURP because it fell short on the ultrasound imaging techniques of the prostate.
The following application of robotic surgery in urology was in helping the urologist with intra-operative percutaneous renal access, a minimally invasive technique for removing kidney stones. Numerous endeavors to build up a accurate, mechanical strategy for percutaneous renal access have prompted a robotic surgical framework that has been adjusted a few times, yet has now exhibited a 87% accuracy in increasing renal access. An amplified clinical trial of the automated framework exhibited rates for the number of attempts, and time to renal access, which were tantamount to the standard procedure (Allaf et al., 2004). Further improvement and on-going clinical trials are necessary to demonstrate that an automated robotic procedure is safer and more accurate than the currently employed renal access techniques.
Towards the latter half of the 1980s, researchers at the National Aeronautics and Space Administration (NASA)- Ames Research Center attempted at developing a technology for virtual reality assisted telemedicine. Virtual reality is defined as "the reproduction of a genuine or envisioned environment that can be visually experienced in the three dimensions of width, length, and depth and that might also give an intuitive visual experience in full continuous movement with sound and probably other kinds of feedback processes". Telemedicine is the idea of a doctor observing, diagnosing, and treating a patient without physically being in the patient's vicinity. Virtual reality interfaces the doctor with the environment the patient is in, and permitting the doctor the perception of being available in this other environment, in a state called as telepresence. Once telepresence has been accomplished, medicinal mechanical technology then permits the doctor to control the environment in which the patient exists without physically being available in that environment. Along these lines medicinal robots is the key component in telemedicine that empowers a doctor to remotely treat a patient.
Operating Room Environment
Robots used in surgery are complicated instruments, both electrically and mechanically, than conventional instruments utilized as a part of the working room environment. Moreover, they include direct external and internal contact with the patient’s body. These vital components separate surgical robots from other hardware, for example, working magnifying instruments, intraoperative imaging instruments and customary operation room instruments.
Besides the specialist and surgical partner, all faculty in the working room must be properly prepared to handle this gear. There are right now no standard criteria put forward for enrolled medical caretakers, surgeons, or specialists regarding fitting training for dealing with these instruments in the operation theatre. In any case, at any rate, operating room faculty ought to be prepared by manufacturer’s preparation protocols, and need to have the chance to be "teamed up" with an accomplished medical attendant or medical technician during their initial stages.
It is seriously prescribed that groups utilizing such instruments – specialists, experts, medical caretakers, and representatives of the manufacturer – meet on an intermittent basis to stay current in their preparation and to learn of upgrades or changes to the equipment or programming. Along these lines, rising issues might be immediately distinguished and tended to.
Virtual reality will probably be fruitful if it is deliberately and systematically introduced into a well-worked out instruction and training program which assesses specialized skill changes to enhance the learning and handling of these instruments. Accepted performance measurements must be pertinent to the surgical assignment being trained. However, as a rule will require trainees to achieve an impartially decided proficiency criterion, taking into account firmly characterized measurements and performs at this level consistently. Virtual reality training will probably be effective if the training schedule happens on an interim premise as opposed to squeezed into a brief time of exhaustive practice. High-performance virtual reality simulations will present the best aptitudes get transferred to the in vivo surgical circumstance. However, inexpensive virtual reality mentors will also help improve generalizing skills considerably.
Personnel and Patient Care
So as to keep up the highest levels of patient care today and later on, we should guarantee that specialists are satisfactorily prepared in the utilization of surgical robots before clinical use. Preparing and credentialing are isolated however personally related issues. Credentialing must be allowed by the individual establishments where surgeons work. There are specific rules involved for credentialing and for training personnel to operate using surgical robots which have been elaborately put down by Herron & Marohn (2008) in appendices 1 and 2.
There are two wide perspectives to training with robotic instruments. The first is specialized training and skill. The specialists and surgeons must have both a strong understanding and practical hands on training experience with these complex instruments before clinical use. Besides all standard working methodology, this preparation must incorporate how to securely and quickly evacuate the robot in a crisis, what to do if the instrument stops working, and how to react if the instrument makes developments that are conceivably dangerous to the patient. All such sensibly predictable circumstances must be foreseen, rehearsed and understood. At present, the FDA has set up a protocol that organizations must provide some training before moving their products. Subsequently, at the very least, surgeons must be prepared to meet these FDA guidelines.
The second part of training includes the utilization of the robot for particular operations. The simplest example is when a completely prepared and capable laparoscopic surgeon starts to utilize a medical robotic system. For this situation, it is only a matter of including the particular information of robotic technology to a current set of medical and surgical skills. A more complicated circumstance is displayed by the surgeon who chooses to start his or her minimally invasive attempts by utilizing the robot. In this circumstance, the measure of learning required might be significantly more noteworthy.
SAGES and MIRA perceive that surgical test systems might assume an undeniably substantial part in surgical preparing later on. In any case, at present there are no test systems that give preparing proportional to that got in a formal clinical setting. In this manner, at present, test systems must remain a subordinate in the preparation of automated surgeons.
Hospitals and other institutions that utilize state of the art technologies such as surgical robots in clinical practice need to develop and adhere to credentialing rules. The start of an robotic surgical project is like the inititation of some other novel, state of the art, direct patient care technology, and ought to require suitable preparing and credentialin. Likewise, every foundation needs to add to a steady arrangement concerning the way of the strategies to be performed with respect to the requirement for IRB oversight. Such approach must consider the way of the proposed technique itself. The foundation likewise has a commitment to keep up the system predictable with manufacturer’s rules.
Patients experiencing robotic surgeries have the same requirement for educating on what's in store postoperatively for pain, movement level, conceivable issues, and care of their surgical regions. They additionally have questions about the robotic procedures and surgical systems that they need to be filled in on. As of now the main accessible patient instruction materials identified with robotic surgeries are general instructions from the manufacturers. Robotic surgery is being talked about in the media in connection to its cutting edge innovation. In any case, there is barely any significant information being instructed to the layman on how therapeutic automated frameworks capacity, and what part they play in medicinal services. Obviously more detailed information for patients is expected to guarantee their comprehension of this treatment alternative, and to encourage their decision making.
Noise and its Effects
Numerous sources, including patient monitoring systems, suction machines, and loud conversations between people, add to the noise that is available in the operating room. The noise levels were measured in the operating room and observed them to be as high as 70 dB (eg, grinding paper waste) to 86 dB, and they are frequently more significant than the suggested standard of 45 dB for an operating environment (Siu, et al 2010). Particularly amid neurosurgical and orthopedic procedures, the levels of noise can be as loud as 100- - 120 dB, which can meddle with the correspondence between surgeons and medical attendants during an operation. Such a loud environment in working rooms could be conceivably perilous to staff and patients, and it could likewise negatively affect the execution of doctors during an operation. Thus, several studies have explored the impact of noise on the execution of an ordinary laparoscopic procedure. Background disturbance at 80- - 85 dB disabled laparoscopic surgeries with respect to dexterity and expanded the frequency of errors.
Conversely, another study on the impact of noise and background music on laparoscopic procedures demonstrated no adjustments in execution with respect to the time taken to complete a suturing assignment, the way length of the hand development, the precision of suturing, and the bunch quality. These opposing results demonstrated the need to build up plainly how environmental impacts such as noise affect surgical procedures. Moreover, literatures on robotic surgery, where the development of the robot can create additional background disturbance, are scarce.
Some results showed that pre-recorded noise in an operating room influences the execution of basic procedures during robotic surgery. All subjects performed the surgeries with no change in both time to complete assignment and total separation of the instrument tips after the procedure while being presented to noise. These outcomes are in accordance with other groups who observed noise to be a psychologic anxiety to the surgeons that obstructs their surgical performance in the operating room. The level of prerecorded noise utilized as a part of a certain study was as high as 90 dB. Such a level of noise has been found to have an adverse effect in the operating room when surgeons performed neurosurgery or different operations requiring uproarious gear like electric drills. A past study has likewise demonstrated that noise could prompt extra burden on specialists and expansion blunders when performing a laparoscopic operation. Subsequent research additionally upheld these past discoveries and demonstrated this is also the case for robotic laparoscopy. Research also uncovered an expansion in muscle enactment volume and a reduction in middle muscle recurrence amid the introduction to noise. These results demonstrated that subjects required more muscle exertion that prompted expanded muscle weariness when they performed mechanical laparoscopic preparing errands amid presentation to noise. Muscle weariness has been connected with agent performance; expanded weariness could prompt poor execution in laparoscopic surgery.
Patient Robot Interaction
Even though robotic surgery has provided significant promise over a wide scope of surgical procedures, no high level information exist right now to unequivocally bolster robot assisted surgery; on the other hand, no research or recounted reports exist to propose any expansion in complexity rates contrasted with traditional open or laparoscopic surgery.
All in all, the research in regards to robot assisted surgery falls behind the clinical experience by quite a long while. Current literature recommends that the essential clinical preferences of as of now accessible robotic systems, contrasted with traditional open or laparoscopic surgery, include:
Higher quality visualisation including 3-D imaging of the operating field
Adjustment of instruments inside of the surgical field
Mechanical benefits over conventional laparoscopy
Enhanced ergonomics for the working surgeon
Over various surgical claims to fame, robot assisted surgery was felt to offer the best point of preference in complex reconstructive procedures.
Impediments of current mechanical innovation include, among other specialized imperatives, absence of haptics, size of the gadgets, instrumentation restrictions (both size and assortment), absence of adaptability of certain power devices, and issues with multi-quadrant surgery (current instruments are conveyed regularly for single quadrant application).
Generally speaking, the in fact outstanding laparoscopic specialist might get little profit by automated surgery. In any case, surgical robots might serve as an "empowering innovation" for some surgeons, permitting them to give complex negligibly intrusive systems to a wide scope of patients. The potential focal points of mechanical surgery reach out crosswise over a wide range of surgical subspecialties.
Cleaning and Sterilizing the Robot
There are intricately planned instruments are multiple use endoscopic instruments. These instruments comprise of discharge levers that are utilized to detach the instrument from the sterile connector of the da Vinci surgical system, the instrument shaft, a wrist and the end effector. Before operating, every one of the instruments ought to be examined for defects or anomalies. All instruments must be analyzed carefully after every procedure and if there are any irregularities recognized, they must not be re-used. While cleaning the handle, every single flush port must be washed with pressurized water. Subsequent to cleaning, clear water ought to be seen leaving the instrument.
The instrument can be cleaned by utilizing a syringe to infuse enzymatic cleaning arrangement into every single flush port. The instruments are then inundated in a ultrasonic shower loaded with an enzymatic cleaning solution for no less than 15 min. The enzymatic arrangement must not achieve a temperature above 98°F (37°C). The exterior of the instrument must be scoured with a delicate, nylon swarmed brush, and the instrument must then be altogether flushed to remove any residue. While scrubbing, move the instrument wrist joint through the full scope of movement. The instruments must be dried before continuing to sanitize them.
As a result of the precision needed in surgery, it is essential to keep certain parts and segments ceaselessly free of outside material for productive operation and keeping up presses at their most elevated worth. Operators must set up intermittent cleaning and support timetables of every single surgical robot to cut upkeep costs and give speedier setups and less re-run's. Simply putting a CO2 blast cleaning machine in un-trained hands may not be the best. Surgical robots are exceptionally complex, compared with most modern hardware, and there are numerous parts that can be damaged through indiscreet and careless impacting. Thusly, a legitimately prepared group of CO2 blast cleaners will have significant effects in the general integrity of the surgical procedure. Cleaning by dry ice is entirely ecologically safe, USDA rated, biodegradable and harmless to humans, animals and aquatic life.
Electrical components of surgical robots can be also be cleaned by dry ice cleaning. This procedure is done with no dampness and results in sparing hours of time for drying. The cold of the dry ice severs the bond of the contaminant quicker than solvents or steam impacting. Just the contaminant should be discarded as the dry ice vanishes into the air. The instrument can be immediately warmed to keep the frosty metal from gathering dampness from the encompassing air when completed with the cleaning.
The da Vinci Robot
In July 2000, the FDA cleared da Vinci as an endoscopic instrument control robot for use in laparoscopic (stomach) surgical systems such as removal of the gallbladder and surgery for serious indigestion. In March 2001, the FDA cleared da Vinci for use in non-cardiovascular thoracoscopic (inside the mid-section) surgical methodology - surgeries including the lungs, throat, and the interior thoracic blood vessels. This is otherwise called the inward mammary artery, which is situated inside the chest cavity. Surgeons disengage the inner mammary during coronary bypass surgery to supply route and reroute it to a coronary artery. In June 2001, the FDA approved da Vinci for use of laparascopic removal of the prostate (radical prostatectomy).
The da Vinci is planned to help with the control of a few endoscopic instruments, including rigid endoscopes, blunt and sharp dissectors, scissors, surgical blades, and forceps. The framework is approved by the FDA to control tissue by getting a handle on, cutting, analyzing and suturing.
The da Vinci Surgical System furnishes doctors with a distinct option for both customary open surgery and ordinary laparoscopy, putting a surgeon’s hands at the controls of a cutting edge mechanical stage. The da Vinci System empowers specialists to perform even the most perplexing and fragile operations through little entry points with unmatched precision and accuracy.
Advantages and Disadvantages of da Vinci
Hospital consultation charges can be reduced upto 33%.
Precision in performing coronary bypass surgery
Reduces pain and facilitates quicker recovery, and consequentially reduces time spent in the ICU
Despite the fact that the size of the instrument is not small for cardiac surgeries in children, the insignificantly intrusive nature of da Vinci does not leave a vast surgical scar and still has some constrained applications in kids for now. In addition, as indicated by Intuitive Surgical, just 80,000 out of 230,000 new instances of prostate cancer experience surgery in light of the high hazard invasive surgery conveys, inferring that more individuals might experience surgery with this developing method.
The fundamental disadvantages to this technology are the precarious expectation to absorb information and high cost of the robot. In spite of the fact that Intuitive Surgical provides a preparation program, it took specialists around 12-18 patients before they felt happy with performing the method. It is time consuming. One of the biggest difficulties confronting surgeons who were preparing on this gadget was that they felt thwarted by the loss of material, or haptic sensation (capacity to "feel" the tissue).
The huge floor-mounted patient-side truck restricts the nurse’s mobility around the patient. In any case, there are several institutions which cannot access the extremely expensive da Vinci.
In a paper distributed by The American Journal of Surgery, 75% of surgeons asserted that they felt monetarily restricted by any technology that cost more than $500,000. Starting now, surgery with the da Vinci Surgical System takes 40-50 minutes longer, yet the FDA considered this an expectation to process information and anticipates that the truth will surface eventually with more utilization of the technology.
Patient safety concerns remain the focal point of center for Intuitive Surgical. To begin the methodology, the surgeon’s head must be put in the viewer. Something else, the framework will bolt and stay still until it perceives the presence of the surgeon’s head at the end of the day. During the operation, a zero-point development system keeps the automated arms from rotating above or at the one-inch section cut, which could somehow or another be unexpectedly torn. Incorporated into the power source is a storage backup battery that permits the framework to keep running for twenty minutes, giving the healing sufficiently center time to restore power. Every instrument contains a chip that keeps the utilization of any instrument other than those made by Intuitive Surgical. These chips likewise store data about every instrument for more exact control and monitor instrument use to decide when it must be supplanted.
Other than the cost, the da Vinci Surgical System still has numerous drawbacks that it must overcome before it can be completely coordinated into the current social insurance framework. From the absence of material input to the substantial size, the present da Vinci Surgical System is simply a harsh preview of what is to come. Expense of $16.2 million in 2003 alone, Intuitive Surgical has a first-mover favorable position over its rivals and keeps on driving on as it gets more FDA endorsements. The table below would help understand the cost and savings per heart surgery using the da Vinci taken from the American Heart Hospital Journal (Chitwood, et al. 2003).
In 2004, the cost of each da Vinci instrument was $1.5 million and there were 76 units that were sold. Since da Vinci is FDA approved for laproscopic and thoracoscopic procedures, Medicare reimbursement is available for these operations.
References
Lanfranco, A. R., Castellanos, A. E., Desai, J. P., & Meyers, W. C. (2004). Robotic surgery: a current perspective. Annals of surgery, 239(1), 14-21.
Allaf, M., Patriciu, A., Mazilu, D., Kavoussi, L., & Stoianovici, D. (2004). Overview and fundamentals of urologic robot-integrated systems. Urologic Clinics of North America, 31(4), 671-682.
Herron, D. M., & Marohn, M. (2008). A consensus document on robotic surgery. Surgical endoscopy, 22(2), 313-325.
Siu, K. C., Suh, I. H., Mukherjee, M., Oleynikov, D., & Stergiou, N. (2010). The impact of environmental noise on robot-assisted laparoscopic surgical performance. Surgery, 147(1), 107-113.
Chitwood, W. R., Kypson, A. P., & Nifong, L. (2003). Robotic mitral valve surgery: a technologic and economic revolution for heart centers. American Heart Hospital Journal, 1(1), 30-39.
