"ROBOT TO THE O.R." THE FUTURE IS NOW

Thinking of robots generally stirs images of Star Wars' R2D2 and 3CPO, and Rosie from the Jetsons. But when it comes to the operating room, AESOP and da Vinci are with whom you may have a close encounter. Computer Motion, Inc., Goleta, CA are the makers of AESOP, and Intuitive Surgical, Sunnyvale, CA is credited with the production of da Vinci.

As surgeries become more microscopic, the technology used to assist and guide surgeons has become disproportionately bigger. Large robotic machines guiding tiny tools have jumped from science fiction to reality, allowing physicians to move with greater ease and accuracy through robotic arms with downsized tools inside a patient's body.

The UT-Houston Physicians pediatric surgeon team employs a camera-toting robot in their operating room, to ensure precise results. This Medical School group is using Automated Endoscopic System for Optimal Positioning, or AESOP, a voice- activated robot that controls the camera during minimally invasive surgeries. AESOP is activated only by the surgeon's voice; the surgeon may record up to 20 commands in millimeter increments.

"Without a robot, a relatively inexperienced person is controlling the camera during these surgeries, and with a 3 kilogram baby, there is usually no room for error," said Martin Blakely, M.D., a pediatric surgeon. "This robotic technology is very precise, safe, and quick."

In 2003,the faculty at The University of Texas Medical School at Houston began to use da Vinci – an imposing three- armed machine that includes a separate workstation for the surgeon, who is seated away from the patient as he controls the surgery and watches every move in 3D color. The surgeon operates the camera arm of the robotic-assistance device with a foot pedal and controls the two instrument arms with his hands, making movements that translate to the endoscopic operation on the nearby patient. A 2D monitor allows others in the room to have a good view of the surgery.

da Vinci's robotic pinchers.

In addition to the standard team of professionals in the operating room, a robot technician attends all surgeries involving da Vinci.

"The robot gives us all of the benefits we normally have with minimally invasive surgery – smaller incisions, quicker recovery, and less pain for the patient," said Erik Wilson, M.D., assistant professor of surgery. "But the da Vinci instruments offer much more flexibility and dexterity, moving like a human wrist, unlike the traditional laparoscopic tools."

The incisions on the patients are 8mm and 12mm in length and are created for the placement of the surgical ports, which are connected to the robot's arms. The instruments are being retooled so that the incisions can be even smaller, and a fourth arm will soon be available to assist in retraction during surgery.

Dr. Porat along with the Department of Cardiothoracic and Vascular Surgery led the charge in bringing da Vinci to UT- Houston, which has been in operation at Memorial Hermann Hospital since July 2003.

"Robotics are helping us take the next step in cardiovascular surgery," Dr. Porat said. "The technology allows us to perform keyhole surgeries (using small incisions) on intracardiac procedures. We are minimizing patient trauma with this technology."

While da Vinci is FDA-approved for any intracardiac operation, Dr. Porat and his colleagues are using it primarily for internal mammary artery take-down. This procedure involves the removal of a primary artery to be used later in coronary artery bypass surgery. Using the robot allows a much smaller incision compared to the traditional surgery for the artery removal.

In the near future, one of the primary objectives will be to use da Vinci for a mitral valve repair surgery. Dr. Porat said he would also like to add other surgical procedures to da Vinci's repertoire and currently is working on a robot-assisted minimally invasive aortic procedure.

A doctor at the controls, manipulating the pinchers.

While the focus of da Vinci is on cardiac surgery, the UT Medical School's Department of Cardiothoracic and Vascular Surgery have allowed other departments to use da Vinci. The Department of Surgery faculty have used the robot to assist in hernia surgery and plan to expand its use to include gastric bypass surgery and gallbladder removal.

While the primary downside of using robotic-assisted devices is the learning curve, the technology is paving the way to benefit patients and surgeons.

"I am confident that robotics will develop to do these procedures better and faster," said Terry Scarborough, M.D., assistant professor of surgery.

Such positive outcomes will make robots in the operating room more common and will change the nature of surgery.

"Cardiac surgery is such a young surgical subspeciality, but it has come so far. In the future, our patients will have a shorter hospital stay and will go home the next day after heart surgery," Dr. Porat said.

Robotics has also made it possible for surgeons to operate across the room, or even across the world, from their patients. An example of this has already been demonstrated by a surgical procedure performed by a surgeon in New York on a patient in France. "NASA and the Pentagon are putting a lot of money into this technology, which one day may allow a surgeon on Earth to operate on an astronaut in space, or on a patient in a submarine," Dr. Porat said.

Dr. Wilson predicts that in 10 years, the vast majority of surgeries will be done with robotic assistance, and in 20 years all surgeries will have such mechanical intervention.

"Eventually, there will be no cords in the way – this is the fist step, using small instruments inside the body," Dr. Wilson said. "In the future, we'll make just one incision and nanotechnology instruments will drive themselves around and fix things. These robots will be able to adapt to specific situations and even reproduce."

Stay tuned … the future may not be as far away as you think.