Overview
Technology is revolutionizing the medical field with the creation
of robotic devices and complex imaging. Though these developments have
made operations much less invasive, robotic systems have their own
disadvantages that prevent them from replacing surgeons. Minimally invasive surgery
is a broad concept encompassing many common procedures that existed
prior to the introduction of robots, such as laparoscopic
cholecystectomy or gall bladder excisions. It refers to general
procedures that avoid long cuts by entering the body through small
(usually about 1cm) entry incisions, through which surgeons use
long-handled instruments to operate on tissue within the body. Such
operations are guided by viewing equipment (i.e. endoscope) and,
therefore, do not necessarily need the use of a robot. However, it is
not incorrect to say that computer-assisted and robotic surgeries are
categories under minimally invasive surgery.
Both computer-assisted and robotic surgeries have similarities when it comes to preoperative planning and registration.
Because a surgeon can use computer simulation to run a practice session
of the robotic surgery beforehand, there is a close tie between these
two categories and this may explain why some people often confuse them
as interchangeable. However, their main distinctions lie in the
intraoperative phase of the procedure: robotic surgeries may use a large
degree of computer assistance, but computer-assisted surgeries do not
use robots.
Computer-assisted surgery (CAS),
also known as image-guided surgery, surgical navigation, and 3-D
computer surgery, is any computer-based procedure that uses technologies
such as 3D imaging and real-time sensing in the planning, execution and
follow-up of surgical procedures. CAS allows for better visualization
and targeting of sites as well as improved diagnostic capabilities,
giving it a significant advantage over conventional techniques. Robotic surgery,
on the other hand, requires the use of a surgical robot, which may or
may not involve the direct role of a surgeon during the procedure. A robot
is defined as a computerized system with a motorized construction
(usually an arm) capable of interacting with the environment. In its
most basic form, it contains sensors, which provide feedback data on the
robot’s current situation, and a system to process this information so
that the next action can be determined. One key advantage of robotic
surgery over computer-assisted is its accuracy and ability to repeat
identical motions.
Further division
Robotic surgery can be further divided into three subcategories
depending on the degree of surgeon interaction during the procedure:
supervisory-controlled, telesurgical, and shared-control. In a supervisory-controlled system,
the procedure is executed solely by the robot, which will act according
to the computer program that the surgeon inputs into it prior to the
procedure. The surgeon is still indispensable in planning the procedure
and overseeing the operation, but does not partake directly. Because the
robot performs the entire procedure, it must be individually programmed
for the surgery, making it extremely expensive to gather several images
and data for one patient. A telesurgical system,
also known as remote surgery, requires the surgeon to manipulate the
robotic arms during the procedure rather than allowing the robotic arms
to work from a predetermined program. Using real-time image feedback,
the surgeon is able to operate from a remote location using sensor data
from the robot. Because the robot is still technically performing the
procedure, it is considered a subgroup of robotic surgery. The da Vinvi®
Surgical System, the current leading device in this field, belongs to
this section of robotic surgery. The third shared-control system
has the most surgeon involvement. The surgeon carries out the procedure
with the use of a robot that offers steady-hand manipulations of the
instrument. This enables both entities to jointly perform the tasks.
Before these procedures can be carried out, robotic surgery requires the
use of computer imaging to diagnose and perform the operation. These
imaging modalities can generate either 3-D figures through computed
tomography (CT) and magnetic resonance imaging (MRI) or 2-D ones through
ultrasonography, fluoroscopy, and X-ray radiography. Out of the various
methods of imaging, the main one in use is computer tomography (CT).
CT scans use back projection and detectors to obtain cross-section
images that are particularly useful when diagnosing cancers and viewing
the chest and the abdomen. This kind of imaging is critical to
diagnosis. Because these images can pinpoint pathologies, the surgeon is
given a great degree of precision in guiding the instruments around
healthy tissue with minimal injury. However, before the procedure can be
carried out, there are three steps that must be overcome: planning,
registration, and navigation. Planning is achieved through the careful
observation of the images that are generated through these different
imaging modalities. The surgeon uses this information to determine
surgical pathways and methodologies. Following this step, the surgeon
must coordinate the image data with the actual patient in a process
known as registration. Once this is achieved, a surgeon or robot can
implement the navigation step. Using the planning and images, surgeons
can manually guide instruments through the patient (computer-assisted)
or robotic arms can carry out the procedure (robotic) using sensor
feedback. The decision between robotic or manual navigation depends on
cost, safety concerns, difficulty of execution, and other factors. These
variables are changing, however, with the advent of cheaper robotic
production methods and added safety features.
Because computer-assisted and robotic surgeries are so integrated, the
advanced imaging techniques and robotics we explore will be classified
as robotic surgery, or computer-assisted robotic surgery. Even if
nothing is ever one hundred percent safe, devices have the potential to
be fatal if they malfunction. Therefore, considerable consternation
exists in the medical field over these equipment. Industries have
attempted to reduce these risks through redundant sensors and robot
movement barriers, but these safety features increase cost, making them
inaccessible to some physicians. Nevertheless, robotic arms can access
the body much easily through the small incisions than a surgeon can, and
can integrate large amounts of data and images to access areas deep
within the body with precision. And though they cannot process
qualitative information to make judgments during the surgery, they are
still able to filter out hand tremors and scale the surgeon’s large
movements into smaller ones in the patient.
Source: Table from Howe, RD, Matsuoka, Y. “Robotics for Surgery.” Annual Review Biomedical Engineering. 1999, 01:213.
As will be seen, robots do not actually replace humans but rather
improve their ability to operate through the small incisions. In
programming these devices, considerable effort is put into creating
proper algorithms, accurate sensors, and improved user interfaces.
Technology is becoming more and more integrated into the medical system.
From imaging systems to preprogrammed robots, each specialty is finding
benefits from these advances. In this website, we will explore the
influence of computer-assisted surgery on neurosurgery, orthopedics,
urology, and cardiology as well as look into current trends and future
outlooks for this growing field in medicine.
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