Tele and robotic surgery

ROBOTIC
AND
TELESURGERY
Dr. Fathi Neana, MD
Chief of Orthopaedics
Dr. Fakhry & Dr. A. Al-Garzaie Hospital
Saudi Arabia
January,10 - 2018

We live in an age of
a new unpreceded
wonders
The wonders of the world are not
seven any more
The inanimate talk to us
We are flying in the air
More than 65,000-Ton can float
over the water in an iron vessel
The Robotic Doctor is already a
reality

‫المتتابعة‬ ‫الحديثة‬ ‫المخترعات‬ ‫وظهور‬ ‫العجائب‬ ‫عصر‬
‫الناس‬ ‫حياة‬ ‫في‬ ‫والمؤثرة‬
‫وسلم‬ ‫عليه‬ ‫هللا‬ ‫صلى‬ ‫رسول‬ ‫قال‬:
(‫أنفسكم‬ ‫بها‬ ‫تحدثون‬ ‫وال‬ ‫ترونها‬ ‫تكونوا‬ ‫لم‬ ‫عظاما‬ ‫أمورا‬ ‫تروا‬ ‫حتى‬ ‫الساعة‬ ‫تقوم‬ ‫ال‬. )
(‫بهذا‬ ‫حدثنا‬ ‫كنا‬ ‫هل‬ ‫تقولون‬ ‫عظاما‬ ‫تستنكرونها‬ ‫أشياء‬ ‫الساعة‬ ‫تقوم‬ ‫أن‬ ‫قبل‬ ‫ستـــرون‬‫ذلك‬ ‫رأيتم‬ ‫فإذا‬
‫الساعة‬ ‫أوائل‬ ‫أنها‬ ‫وأعلموا‬ ‫تعالى‬ ‫هللا‬ ‫فاذكروا‬.)
...(‫ع‬ ‫مريم‬ ‫ابن‬ ‫عيسى‬ ‫فيهم‬ ‫فيصبح‬ ً‫ا‬‫شديد‬ ً‫ال‬‫زلزا‬ ‫فيتزلزلون‬ ‫المقدس‬ ‫بيت‬ ‫في‬ ‫المؤمنين‬ ‫يحصر‬ ‫وأنه‬‫ليه‬
‫فتعال‬ ‫بي‬ ‫يستتر‬ ‫كافر‬ ‫هذا‬ ‫مؤمن‬ ‫يا‬ ‫لينادى‬ ‫الشجرة‬ ‫وأصل‬ ‫الحائط‬ ‫جذم‬ ‫أن‬ ‫حتى‬ ‫وجنوده‬ ‫هللا‬ ‫فيهزمه‬ ‫السالم‬
‫أقتله‬‫لكم‬ ‫ذكر‬ ‫نبيكم‬ ‫كان‬ ‫هل‬ ‫بينكم‬ ‫تساءلون‬ ‫أنفسكم‬ ‫في‬ ‫شأنها‬ ‫يتفاقم‬ ً‫ا‬‫أمور‬ ‫ترو‬ ‫حتى‬ ‫ذلك‬ ‫يكون‬ ‫ولن‬‫منها‬
‫بيده‬ ‫وأشار‬ ‫القبض‬ ‫ذلك‬ ‫أثر‬ ‫على‬ ‫ثم‬ ‫مراسيها‬ ‫عن‬ ‫جبال‬ ‫تزول‬ ‫وحتى‬ ‫ذكر‬)
‫الجماعة‬ ‫إتحاف‬‫الساعة‬ ‫وأشراط‬ ‫والمالحم‬ ‫الفتن‬ ‫في‬ ‫جاء‬ ‫بما‬
‫هللا‬ ‫رحمه‬ ‫التويجري‬ ‫هللا‬ ‫عبد‬ ‫بن‬ ‫حمود‬ ‫الشيخ‬

When we talk about robots doing
the tasks of humans, we often talk
about the future.
But robotic surgery is already a
reality.
The surgeon views the patient via
a terminal and manipulates
robotic surgical instruments via a
control panel.

The surgeon views the patient via a terminal and manipulates
robotic surgical instruments via a control panel.

The difference between Endoscopic
surgery (as laparoscopic surgery)
and Robotic surgery is that
The instruments are controlled by
the Robotic system in stead of the
direct hold by the human (surgeon)
hands

Robotics does not replace
Human intelligence
Skill
Experience
RobotSurgeon

Robotics does not replace Human intelligence, Skill and
Experience

Should you be scared of robotic surgery?

Pedicle screw instrumentation :
1- Free hand (FH) conventional pedicle screw
instrumentation
15.3% error rate for 544 screws from T5 to S1
7 patients necessitated reoperation
4 patients sustained long-term neurological sequelae
2- Computer assisted navigation (CAN) and surgical
robotics
5.4% error rate for the 294 screws
No patients required reoperation in the CAN group
None experienced postoperative neurological deficits.
Navigation and Robotics in Spinal Surgery: Where Are We Now?
Neurosurgery 80:S86–S99, 2017
VOLUME 80 | NUMBER 3 | MARCH 2017 Supplement www.
Samuel C. Overley, MD∗, Samuel K. Cho, MD∗, Ankit I. Mehta, MD‡, Paul M. Arnold, MD§
∗The Mount Sinai Hospital, Icahn School of Medicine, New York, New York; ‡University of Illinois, Hospital
and Health Sciences Center, Chicago, Illinois; §The University of Kansas Hospital, Kansas City, Kansas

These systems have the potential to
improve the safety and effectiveness
of surgeries.
Three major advances aided by
surgical robots:
Remote surgery,
Minimally invasive surgery, and
Unmanned surgery.

ROBOTIC
AND
REMOTE SURGERY
(TELESURGERY)

Evolution of fracture management
• Before 1950’s - External Splints & Fixation.
• After 1950’s - 1958 - Unstable internal fixation
• 1958 – 1960 ->> 1990 - Rigid internal fixation
Absolute mechanical stability (Aggressive Traumatology)
• After 1990’s - Biological Osteosynthesis Limiting Surgical
trauma
(SIRS vs. CARS - 2nd Hit by surgery)
1- less invasive surgical techniques
2- Limited Implant contact
• After 2000 - Computer-assisted surgery (CAS or CAOS)
utilizing Robotic or image-guided technologies
• Remote surgery (also known as Telesurgery)
Mechanical Internal
fixation Learning
curve
Biology
Biochemistry
Computer, Space, 3D
imaging, Anatomy,
Surgical approaches

Open Reduction Condemned
except in
Articular fractures
Forearm fractures

CLOSED, INDIRECT
REDUCTION
MINIMAL INVASIVE
MIPO
LESS INVASIVE
LISS
LCP
LCP (Preshaped implants)
KEY HOLE SURGERY
(Endoscopic – Arthroscopic -
Laparoscpic)

MINIMAL INVASIVE PLATE OSTEOSYNTHESIS
(MIPO)

The Biological new Surgical
techniques
(Closed Reduction)
Needs
Alignment control

Alignment Control
Length
Angulation
Rotation
X-rays
Image Intensification
Computer Assistance
CLOSED, INDIRECT
REDUCTION
MINIMAL INVASIVE
MIPO
LESS INVASIVE
LISS
LCP
LCP (Preshaped implants)
KEY HOLE SURGERY
(Endoscopic – Arthroscopic -
Laparoscpic)

LENGTH
ANGULATION
Cable Tech
ROTATION

Image intensification
just a real-time images

Computer Assisted
Orthopedic Surgery
(CAOS)
1- Computer science
2- Space digitization
3- 3D Imaging technology
4- Surgical techniques
1- Surgical navigation
2- Robotic assistance

Reduction Maneuver
Robot system
Surgical navigation

Robotic surgery
Remote surgery
(Telesurgery)

The surgeon instead of directly moving the instruments, He uses one of two
methods to control the instruments;
1- Direct telemanipulator
. A remote manipulator that allows the surgeon to perform the normal movements
associated with the surgery (on simulator) whilst the robotic arms carry out those
movements using end-effectors and manipulators to perform the actual surgery on the
patient.
2- Computer control systems
The surgeon uses a computer to control the robotic arms and its end-effectors, (these
systems can also still use telemanipulators for their input).
One advantage of using the computerized method is that the surgeon does not
have to be present, but can be anywhere in the world, leading to the possibility
for remote surgery.
Robotically-assisted minimally-invasive surgery
and Remote surgery (Telesurgery)

Robotic surgery
Robotic surgery is a type of
minimally invasive surgery.
“Minimally invasive” instead
of operating on patients
through large incisions,
we use miniaturized surgical
instruments that fit through a
series of quarter-inch
incisions.

Robotic surgery
The main object of such smart
instruments is to reduce or
eliminate the tissue trauma
traditionally associated with
open surgery without
requiring more than a few
minutes' training on the part
of surgeons.

Why Robotic Surgery
A robot is not just a machine
It is an information system with
arms
The robots are actually more
accurate than Human beings
(Robotic Pedicular screws error 5% vs. 11% human experts vs.
40% human learning curve)

Total Integration of Surgical Care
Courtesy of Joel Jensen,
SRI International, Menlo Park, CA
Minimally Invasive
& Open Surgery
Pre-operative planning
Surgical Rehearsal
Intra-operative navigation
Remote Surgery
Simulation & Training
Pre-operative Warm-up

APPLICATIONS
• Cardiac surgery
• Gastrointestinal
surgery
• Gynecology
• Neurosurgery
• Orthopedics
• Pediatrics
• Radio surgery
• Urology
Different procedures, including:
Coronary artery bypass
Cutting away cancer tissue from sensitive
parts of the body such as blood vessels,
nerves, or important body organs
Gallbladder removal
Hip replacement
Hysterectomy
Kidney removal
Kidney transplant
Mitral valve repair
Pyeloplasty (surgery to correct ureteropelvic
junction obstruction)
Pyloroplasty
Radical prostatectomy
Radical cystectomy
Tubal ligation

Da Vinci Surgical System
ZEUS Robotic Surgical
System
AESOP Robotic System
There are three surgical robots that have
been recently developed

Surgical Robot - “Da vinci”
4 arms
• Da vinci’s miniaturized instruments are mounted on
three separate robotic arms, allowing the surgeon
maximum range of motion and precision. The da Vinci’s
fourth arm contains a magnified high-definition 3-D
camera that guides the surgeon during the procedure.
Da vinci is the one of the most
advanced Surgical bot in the
world.

ES159/259
Da Vinci System
Video
display
patient
surgeon
Robot arms
console

Da Vinci robot consists
• A surgical console
• Patient- side cart
• Instruments and imaging processing equipment

The surgeon views the patient via a terminal and manipulates robotic surgical
instruments via a control panel.

Da Vinci Components
Surgeon’s Console
• Optimal hand-eye
alignment
• Immersive 3D stereo
viewer
• Comfortable seat
posture – ergonomic
• Motion scaling &
tremor reduction
Master controller controls the motion of the end effector wrist

Da vinci Cart
•Endowrist instruments
•3-4 robotic arms
•Interchangeable end
effectors
Da Vinci Components

Da Vinci System
• Multiple robotic arms
– For camera control and end
effector control
Stereo endoscope
Tools at arms of bot

The Endoscope
• Fiber optic instrument
• Inserted through a small
incision
• Has a very tiny video camera
• Shows the surgeon a 3-
dimensional, magnified view
• Projects to a television screen

Speciality of Da vinci
The surgeon controls these instruments and the camera from
a console located in the operating room. Placing his fingers
into the master controls, he is able to operate all four arms of
the da Vinci simultaneously while looking through a
stereoscopic high-definition monitor that literally places him
inside the patient, giving him a better, more detailed 3-D view
of the operating site than the human eye can provide

Robotic and Remote surgery (Telesurgery)
Robotic surgery is a type of rapidly
advancing minimally invasive
surgery.
A robot is not just a machine
It is an information system with
arms
The robots are actually more
accurate than Human beings

• Surgeons have enhanced view
• Easier to attach nerve endings
• Surgeons tire less easily
• Fewer doctors required in operating
rooms
• In turn, cheaper for hospitals.
• Smaller risk of infection
• Less anesthesia required
• Less loss of blood
Benefits of Robotic Surgery (Operative)

Benefits of Robotic Surgery (Post operative)
• Operations through small tiny
incisions less scarring
• Faster recovery time
• Reduce loss of healthy tissue
• Less pain, shorter hospital stay
• Reduced cost
• Patient returns to work sooner
• Greater surgical precision
• Less blood loss and transfusion.

• Time lag between surgeons commands and
action of robot could harm the patient
(fiber optic)
• Loss of power in an electrical failure
• Robotics does not replace human
intelligence, skill and experience
• Surgericals Robots are much
costlier - Da vinci's cost is 2.5 million euro.
Legal/Ethical issue in Robotic surgery

• The rate of discovery of new technology is
outpacing the ability of business, society,
and healthcare to integrate and apply
• Robotic surgery is but one example of such
technology that may reduce operative
morbidity, hospital stay, and recovery, while
potentially improving clinical outcomes
• But at what point do the benefits justify the
increased expense?
Legal/Ethical issue in Robotic surgery

Figure 1. Annual Numbers of Adverse Event Reports and Rates of Events per Procedure
The left Y-axis corresponds to the bars showing the absolute numbers of adverse events (based on the year that
reports were received by the FDA). The right Y-axis corresponds to the trend lines showing (in logarithmic scale)
the annual number of adverse events per 100,000 procedures (based on the year the events occurred). Numbers on
the bars indicate number of deaths reported per year. Error bars represent 95% confidence intervals for the
proportion estimates. Because of the small number of injury and death events reported for 2004 and 2005, a
combined rate was calculated for 2004–2006. Note that of all the events, 40 were reported as part of the articles or
the legal disputes received by the manufacturing company.
DISADVANTAG
ES
The Question
of
Safety & Cost

During the study period
1- 144 deaths (1.4% of the 10,624
reports)
2- 1,391 patient injuries (13.1%)
3- 8,061 device malfunctions
(75.9%) were reported
14 year period of 2000–2013
Adverse Events in Robotic Surgery:
A Retrospective Study of 14 Years of FDA Data
specialties, for which robots
are extensively used, such as
gynecology and urology, had
lower number of injuries,
deaths, and conversions per
procedure
than more complex surgeries,
such as cardiothoracic and
head and neck

Device and instrument malfunctions, such as
falling of burnt/broken pieces of instruments into the patient (14.7%),
electrical arcing of instruments (10.5%),
unintended operation of instruments (8.6%),
system errors (5%), and video/imaging problems (2.6%), constituted a major
part of the reports.
Device malfunctions impacted patients
in terms of injuries or procedure interruptions. In 1,104 (10.4%) of the events,
the procedure was interrupted to restart the system (3.1%), to convert the
procedure to non-robotic techniques (7.3%), or to reschedule it to a later time
(2.5%)
8,061 device malfunctions (75.9%) were reported

Figure 2. Cumulative rates of malfunctions per
procedure
The rates of malfunctions per procedure were obtained
for each week (see Figure 2 in Appendix for more
details).
Limitations
The results of our study come with
the caveats that inherent risks
exist in all surgical procedures
(more so in complex procedures)
and that the MAUDE database
suffers from underreporting and
inconsistencies.
Thus, the estimated number of
adverse events per procedure are
likely to be lower than the actual
numbers in robotic surgery.
Further, the lack of detailed
information in the reports makes
it difficult to determine the exact
causes and circumstances
underlying the events.
Therefore, the sensitivity of
adverse event trends to changes
in reporting mechanisms, surgical
team expertise, and inherent risks
of surgery could not be assessed
here.

Despite widespread adoption of robotic
systems for minimally invasive surgery, a non
negligible number of technical difficulties and
complications are still being experienced
during procedures. Adoption of advanced
techniques in design and operation of robotic
surgical systems may reduce these preventable
incidents in the future.
Copyright © 2015: Authors.
While the robotic surgical systems have been successfully adopted in many different
specialties, this study demonstrates several important findings: (1) the overall numbers of
injury and death events per procedure have stayed relatively constant over the years, (2)
the probability of events in complex surgical specialties of cardiothoracic and head and
neck surgery has been higher than other specialties, (3) device and instrument
malfunctions have affected thousands of patients and surgical teams by causing
complications and prolonged procedure times.
As the surgical systems continue to evolve with new technologies, uniform standards for
surgical team training, advanced human machine interfaces, improved accident
investigation and reporting mechanisms, and safety-based design techniques should be
developed to reduce incident rates in the future.

ِّ‫ه‬ِّ‫ب‬ ‫وا‬ُ‫ر‬ِّ‫ك‬ُ‫ذ‬ ‫ا‬َ‫م‬ ‫وا‬ُ‫س‬َ‫ن‬ ‫ا‬َّ‫م‬َ‫ل‬َ‫ف‬َ‫ْو‬‫ب‬َ‫أ‬ ْ‫م‬ِّ‫ْه‬‫ي‬َ‫ل‬َ‫ع‬ ‫ا‬َ‫ن‬ْ‫ح‬َ‫ت‬َ‫ف‬ٍ‫ء‬ْ‫ي‬َ‫ش‬ ِّ‫ُل‬‫ك‬ َ‫اب‬ِّ‫ب‬ ‫وا‬ُ‫ح‬ ِّ‫ر‬َ‫ف‬ ‫ا‬َ‫ذ‬ِّ‫إ‬ ٰ‫ى‬َّ‫ت‬َ‫ح‬‫م‬ُ‫ه‬‫ا‬َ‫ن‬ْ‫ذ‬َ‫خ‬َ‫أ‬ ‫وا‬ُ‫ت‬‫و‬ُ‫أ‬ ‫ا‬َ‫م‬
َ‫ون‬ُ‫س‬ِّ‫ل‬ْ‫ب‬ُّ‫م‬ ‫م‬ُ‫ه‬ ‫ا‬َ‫ذ‬ِّ‫إ‬َ‫ف‬ ً‫ة‬َ‫ت‬ْ‫غ‬َ‫ب‬(44)
‫األنعام‬ ‫سورة‬
So when they forgot that by which they had been reminded,
We opened to them the doors of every [good] thing until, when
they rejoiced in that which they were given, We seized
them suddenly, and they were [then] in despair.
Reviewing the history of mankind's cumulative
experience starting with the ancient very
primitive trials and ending with the presence
of Robotic and Telesurgery
Clearly show that the major and rapid
advances in the whole mankind's life occur
only in the last few decades especially the last
10 years ?

REFERENCES
• http://en.wikipedia.org/wiki/Robotic_surgery
• http://www.medicalnewstoday.com/articles/15
3737.php
• http://robotic-surgery.med.nyu.edu/for-
patients/what-robotic-surgery
• http://www.healthcommunities.com/female-
cancers/what-is-a-gynecologic-oncologist.shtml
• http://www.davincisurgery.com

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