A bird’s eye view of computer assisted surgery
By Sanjiv Kataria
Like many people, I have always been squeamish about entering a prison or a hospital. When Dr Mahendra Bhandari, Director Robotic Research and Education, Vattikuti Urology Institute at Michigan-based Henry Ford Hospital, suggested that I watch a computer assisted surgery using a Surgical Robot (SR) as part of my recent assignment with Vattikuti Foundation, I put up a brave face to be inside an Operation Theatre (OT).
Wearing a blue scrub – a sterile gown – a face mask, and a cap on the head and slipper covers, I was happy that I walked into the OT, as opposed to being wheeled into one on a stretcher, in a 1,000-bed hospital in a South Indian city.
As I entered the OT, a clinical specialist Robin Verma reassured me that this being a minimally invasive surgery I would not see blood or hear groans of a patient who had just undergone a surgery. Robotic surgery, he said, has overcome the difficulties of blood loss, pain, post-operative infection and long hospital stays faced by patients undergoing open surgeries.
A daunting da Vinci Surgical Robot, neatly laid out instruments, even as an eight-member team of surgeons, anaesthetists, nurses and technicians, in their green or blue scrubs, geared up for a Robotic Surgery (RS). I was told that RS assures a healthier post-operative life for someone suffering from life threatening conditions in the digestive, respiratory, urinary, reproductive and other vital body systems.
New York’s Memorial Sloan Kettering Hospital’s Director, Minimal Access and Robotic Surgery Program, Dr Mario Leitao Jr., is by the side of a middle aged patient to be operated for hysterectomy (removal of uterus with cancerous tissue).
A gynaecology cancer surgeon from the local hospital is leading the Indian team. The gynaecologist has already got prior experience having trained in RS at the US-based training centre of SR maker Intuitive Inc. facility and has conducted over 100 robotic surgeries. Together she and the team of anaesthetists had gone over the patient’s medical condition and discussed the reports with Dr Mario when the patient was admitted the previous evening.
All robotic surgeons, I learn, attend the mandatory training and conduct surgeries under the proctorship of senior surgeons. Since the da Vinci Surgical Robot has a ‘driving school car equivalent controls’ with the trainer holding the master controls, the patient is at no risk.
Post-anaesthesia administration, a small abdominal area is used for making 10-12 millimetre incisions using Trocars, four in number. The incisions allow four arms of the SR slide through four separate cannula. A da Vinci Surgical Robot, roughly of the dimensions of a traditional X-Ray machine, has four arms that can move literally in any direction. Each arm, covered with loose plastic material, keeps the robot sterile for subsequent procedures.
While the OT was well lit, I found the absence of a light-head, over the patient that one usually sees in surgery scenes in movies, a bit odd. I learnt that one arm carries two miniature cameras whose 3-dimensional output is displayed on a console a few feet away. The camera arm also has strong lights to illuminate the inside of the area to be operated. This console serves as surgeon’s operating table from where he manoeuvres various surgical instruments with two joystick like controls.
The cameras, I learn, are powerful enough to give vivid images that can be blown up 10 times to provide greater precision during procedures. The 3-D view is much more accurate and gives a clearer view than you get while watching a 3-D movie on a screen 200 feet away because the object as seen on a SR console is extremely close to the eyes. This, I learn, is possible because the image on the two ocular pieces is delivered by two separate cameras.
The other arms of the robot that slip through the hole are equipped with versatile surgical instruments. The instruments are designed to provide movement that is far superior to a human hand and can moderate movements of even a shaking hand. I could see how thin layers of cancerous tissue are separated, blood vessels are cauterised, to avoid blood loss, and joined back. The fourth arm serves as an assistant’s arm for traction and counter traction.
An identical view of the inside of the operating area is displayed on a large screen for the OT doctors, nursing staff and technicians to see and assist the surgeon. The staff, I could notice, was well trained and able to almost predict the next need of the robotic surgeon. More actions are triggered by eye movements of the surgeon than the spoken word.
The endo-wrist movement gives surgical instruments seven degrees of freedom to give a range of motion greater than the human hand. A technician explains seven degrees of freedom as: Imagine your having to tighten a nut at the bottom of the car from inside the bonnet, without raising the car on a mast. A surgical robot allows you to do that inside a human body.
Robotic surgery overcomes these difficulties by bringing in three-dimensional (3D) vision, which provides depth perception. Intuitive movement of the instruments makes procedures like suturing akin to the way it is done in an open surgery. And additionally, the surgeon is able to use three instruments simultaneously, which makes this the most versatile and least time consuming form of surgery today.
Robotic surgery, Dr Bhandari stresses, is all about better vision, precision and control, all designed to help a surgeon deliver better patient outcomes.