Special article
Medicine and robotics
Medicina y robótica
Servicio de Cirugía Gastroenterologia, Hospital Clínic, Barcelona, Spain
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"documento" => "article" "crossmark" => 1 "subdocumento" => "rev" "cita" => "Med Clin. 2015;145:488-92" "abierto" => array:3 [ "ES" => false "ES2" => false "LATM" => false ] "gratuito" => false "lecturas" => array:1 [ "total" => 0 ] "en" => array:12 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Review</span>" "titulo" => "Large vessels vasculopathy in systemic sclerosis" "tienePdf" => "en" "tieneTextoCompleto" => "en" "tieneResumen" => array:2 [ 0 => "en" 1 => "es" ] "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "488" "paginaFinal" => "492" ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Vasculopatía de grandes vasos en la esclerosis sistémica" ] ] "contieneResumen" => array:2 [ "en" => true "es" => true ] "contieneTextoCompleto" => array:1 [ "en" => true ] "contienePdf" => array:1 [ "en" => true ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "Beatriz Tejera Segura, Iván Ferraz-Amaro" "autores" => array:2 [ 0 => array:2 [ "nombre" => "Beatriz" "apellidos" => "Tejera Segura" ] 1 => array:2 [ "nombre" => "Iván" "apellidos" => "Ferraz-Amaro" ] ] ] ] ] "idiomaDefecto" => "en" "Traduccion" => array:1 [ "es" => array:9 [ "pii" => "S0025775315000366" "doi" => "10.1016/j.medcli.2014.12.016" "estado" => "S300" "subdocumento" => "" "abierto" => array:3 [ "ES" => false "ES2" => false "LATM" => false ] "gratuito" => false "lecturas" => array:1 [ "total" => 0 ] "idiomaDefecto" => "es" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0025775315000366?idApp=UINPBA00004N" ] ] "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2387020616300286?idApp=UINPBA00004N" "url" => "/23870206/0000014500000011/v1_201604300039/S2387020616300286/v1_201604300039/en/main.assets" ] "en" => array:15 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Special article</span>" "titulo" => "Medicine and robotics" "tieneTextoCompleto" => true "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "493" "paginaFinal" => "495" ] ] "autores" => array:1 [ 0 => array:4 [ "autoresLista" => "Raquel Bravo, Antonio M. Lacy" "autores" => array:2 [ 0 => array:4 [ "nombre" => "Raquel" "apellidos" => "Bravo" "email" => array:1 [ 0 => "rbravo@clinic.ub.es" ] "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] 1 => array:2 [ "nombre" => "Antonio M." "apellidos" => "Lacy" ] ] "afiliaciones" => array:1 [ 0 => array:2 [ "entidad" => "Servicio de Cirugía Gastroenterologia, Hospital Clínic, Barcelona, Spain" "identificador" => "aff0005" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Medicina y robótica" ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Computers have become a very important part of everyday life, with applications in many career fields, including medicine. At present, countless new disciplines continue to be developed, such as nanotechnology, medical telecare, image-guided surgery or robotic assisted surgery. This computer and digital revolution taking place in medicine leads us to generate new diagnostic and therapeutic modalities and surgical management, as well as to improve surgical training.<a class="elsevierStyleCrossRef" href="#bib0130"><span class="elsevierStyleSup">1</span></a> The main progress over the last 50 years has been the emergence of minimally invasive surgery, as numerous procedures have been adapted to endoscopic techniques for the benefit of patients. Today, these benefits are well known and they include less postoperative pain, shorter hospital stays, more comfortable postoperative course and the best aesthetic results, among others.<a class="elsevierStyleCrossRef" href="#bib0135"><span class="elsevierStyleSup">2</span></a> In laparoscopic surgery, the surgeon maintains control, directly manipulating the patient's tissue through a supporting point in the abdominal wall. With robotic surgery this changes since the surgeon enters a virtual environment outside the sterile field, with an indirect and distant control over the intervention. Robotic technology was developed in an attempt to reduce many of the limitations of laparoscopy, while maintaining its minimally invasive nature. Robotic systems are capable of overcoming the fulcrum effect, poor depth perception, the instrument's limited movement ability and tremor.<a class="elsevierStyleCrossRef" href="#bib0140"><span class="elsevierStyleSup">3</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">According to SAGES, robotic surgery is defined as a surgical procedure performed with technology that facilitates interaction between surgeon and patient during surgery, assuming a certain level of control which used to be fully reserved for the surgeon. The aim of the surgical robot is to correct human deficiencies and enhance their skills, be able to repeat tasks with precision and reproducibility.<a class="elsevierStyleCrossRef" href="#bib0145"><span class="elsevierStyleSup">4</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">In 2001, Dr. Marescaux performed the first tele-robotic operation by means of the ZEUS<span class="elsevierStyleSup">®</span> Surgical System. It was a cholecystectomy performed by surgeons located in New York to a 62-year-old patient with cholelithiasis hospitalized in Strasbourg (France).<a class="elsevierStyleCrossRef" href="#bib0150"><span class="elsevierStyleSup">5</span></a> The ZEUS<span class="elsevierStyleSup">®</span> system consists of a control console for the surgeon, a three-dimensional video system that projects images remotely, and an operating table with 3 robotic arms and 4 motion ranges. The right and left arms simulate the arms of the surgeon, while the third arm is a voice-controlled AESOP<span class="elsevierStyleSup">®</span> robotic endoscope.<a class="elsevierStyleCrossRef" href="#bib0155"><span class="elsevierStyleSup">6</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">Telepresence surgery, also called robotic surgery or computer-assisted surgery, is a computerized interactive system, so fast and intuitive that the computer disappears from the mind of the surgeon, transforming the environment generated by the system as something real. Through virtual reality, the surgeon determines the manoeuvres to be executed by the robot in the patient. The control console where the surgeon works can be in the same operating room, or elsewhere in the same city or even in another country. Robotic and telepresence surgery is based on two fundamental concepts that are, on the one hand, virtual reality, and on the other, cybernetics. The effects of 3D immersion, navigation, interaction and simulation are achieved with virtual reality, all in real-time, i.e., what you see in 3D on the monitor is real and what is touched through the robot is also real. Cybernetics is the branch of computer science that digitizes the movement, and is divided into 3 major areas, which are the automaton, bionics and robotics. The latter studies the development of robots, programmed articulated mechanisms, with mechanical parts, motors, degrees of freedom, cameras, sensors, transducers, data storage, specialized programmes for data processing, optimization functions and interfaces connected to elements that execute specific tasks.</p><p id="par0025" class="elsevierStylePara elsevierViewall">Robots can be autonomous (those who need a programme designed to perform certain activities) or slaves (those who have no capacity for autonomous movement and are absolutely dependent). Telepresence surgery uses a slave robot, which cannot make any movement without the surgeon's orders and, therefore, is dependent on the judgement, knowledge and skills of the doctor. It consists of a structure that resembles the anatomy of human arms, able to mimic the movements of various joints such as the shoulder, elbow, wrist and fingers.</p><p id="par0030" class="elsevierStylePara elsevierViewall">The system called da Vinci<span class="elsevierStyleSup">®</span>, from Intuitive Surgical Inc., is one of the most popular in the world, consists of the following elements: master console, slave robot, instrumentation, graphical user interface and image acquisition system. To get us into a real situation, the surgeon sits comfortably in a chair that can adjust its height and proximity as he/she wishes with respect to the master console, and places his/her head in a way that his eyes adjust to the scope, allowing him/her to see real images inside the patient magnified up to 20 times the actual size and in 3D. The assistant surgeon makes incisions for the placement of the ports of entry in the most appropriate location according to the organ to be operated on. These input ports are coupled to the robot and through them both the optics and the necessary instruments are inserted to perform the procedure. The movements of both, the optics as well as the instruments, originate in the specialist hands, but only using a pair of fingers and with very high precision. If the instruments in the robot arms need to be changed, this is done manually by the assistant.</p><p id="par0035" class="elsevierStylePara elsevierViewall">Anyway, the da Vinci<span class="elsevierStyleSup">®</span> robotic surgical system also has drawbacks. The main one remains to be the size, which limits the space in the operating room. It also requires a large number of delicate connections that are inside the operating room and that can cause accidents or suffer damage. In addition, interventions that require access to more than one abdominal quadrant force the assembly and disassembly of the robotic arms, which leads to increased time, both surgical as well as anaesthetic.<a class="elsevierStyleCrossRef" href="#bib0160"><span class="elsevierStyleSup">7</span></a></p><p id="par0040" class="elsevierStylePara elsevierViewall">Despite the many technological advances, surgical training has remained unchanged for over a century. Surgical residents have had to gain experience with the monitored trial and error system applied in real patients. This approach makes training in surgery entirely dependable on the number of operable cases available at the time, prolongs the learning curve and compromises patient safety.<a class="elsevierStyleCrossRef" href="#bib0165"><span class="elsevierStyleSup">8</span></a> Robotic surgery will become a new means to acquire the necessary skills to operate, thanks to the simulation of all operations that can be performed with the robot. Surgeons can use surgical robots to practice operations with three-dimensional virtual reality simulators and soft tissue models that recreate the texture of human tissues through <span class="elsevierStyleItalic">Force Feedback</span><a class="elsevierStyleCrossRef" href="#bib0170"><span class="elsevierStyleSup">9</span></a> systems. The image-guided simulations allow surgeons to practice different interventions thanks to three-dimensional reconstructions of the part of the anatomy that will be subject to surgery the following day. It is expected that these systems help perfecting the learning process, allowing residents to acquire surgical skills in a reduced period of time, while patient safety is improved by preventing errors in the interventions. Ultimately these applications will become an integral part of the training and accreditation of surgeons, and provide objective means to assess surgical skills.<a class="elsevierStyleCrossRef" href="#bib0175"><span class="elsevierStyleSup">10</span></a> Currently, there are approximately 2100 robots in the USA and 520 in Europe, including about twenty in Spain. However, there is no formal training programme for robotic surgery yet. The Halsted saying “see one, do one, teach one” is being replaced by a more structured teaching philosophy, particularly following the introduction of laparoscopy, a much more democratic and participatory surgery. A joint programme between the American Society of Colorectal Surgeons and Intuitive Surgical Inc. makes it easier for residents to carry out a three-day course in laboratory with experimental animals and corpses. Urologists from North America and the UK have designed a curriculum based on virtual reality where the main skills to be acquired in robotic surgery, including orientation, motor skills, basic and intermediate surgical skills are collected. Likewise, a 3-month programme designed by the European Society of Robotic Urology includes theoretical sessions, skills training, observation of actual cases in training centres and assistance both by the patient and at the console. The European Academy of Colorectal Robotic Surgery was founded in June 2014. This is a coordinating unit with 10 participating European centres. The training programme is open to colorectal expert surgeons in both open and laparoscopic surgery, with access to the robotic system in their own hospital. The training includes familiarization with the system, interventions with both, experimental animals and corpses, and observation and practice in real cases with the intention of eventually developing unassisted surgery. Far from deciding whether robotic surgery is indicated or not, what is certain is that training in minimally invasive surgery has revolutionized traditional surgery learning, emphasizing communication and team training.</p><p id="par0045" class="elsevierStylePara elsevierViewall">From a purely pragmatic view point and with the imminent arrival of new technologies to perform the same intervention, the dilemma arises for the surgeon regarding whether the robotic system brings any benefit to the technique typically used, taking into account that the said benefit has a direct impact on the welfare of the patient. That's why we could analyze some of the procedures individually.</p><p id="par0050" class="elsevierStylePara elsevierViewall">Radical prostatectomy is the intervention where robotic surgery has shown greater advantages over open and laparoscopic surgery, including a reduction in complications, a shorter hospital stays and an increased rate of surgical specimens with disease free margins,<a class="elsevierStyleCrossRef" href="#bib0180"><span class="elsevierStyleSup">11</span></a> although an increase in the operating time persists.</p><p id="par0055" class="elsevierStylePara elsevierViewall">Heller myotomy by laparoscopy is effective for patients with symptomatic achalasia, although there are series describing an oesophageal perforation rate of up to 16%.<a class="elsevierStyleCrossRef" href="#bib0185"><span class="elsevierStyleSup">12</span></a> Studies comparing robotic myotomy with laparoscopic show a perforation rate of 0% against 6–8%, probably due to the better visualization of muscle fibres and more controlled robot movements.<a class="elsevierStyleCrossRef" href="#bib0190"><span class="elsevierStyleSup">13</span></a></p><p id="par0060" class="elsevierStylePara elsevierViewall">A meta-analysis<a class="elsevierStyleCrossRef" href="#bib0195"><span class="elsevierStyleSup">14</span></a> of 6 prospective randomized studies comparing laparoscopic fundoplication versus robotic, and including a total of 226 patients, showed comparable results with both techniques, but increased operating time and increased costs for robotic surgery.</p><p id="par0065" class="elsevierStylePara elsevierViewall">Regarding the oesophagectomy, the magnified view of the robotic platform should theoretically facilitate dissection in a small space such as the mediastinum, and improve oncological results in terms of disease-free margins and resected lymph nodes quantity. This is shown in a systematic review of 9 series of cases involving a total of 130 patients.<a class="elsevierStyleCrossRef" href="#bib0200"><span class="elsevierStyleSup">15</span></a></p><p id="par0070" class="elsevierStylePara elsevierViewall">In a comparative study including 827 patients suffering from gastric cancer, 236 gastrectomies were performed robot-assisted and 591 laparoscopic. The mean duration of surgery was 49<span class="elsevierStyleHsp" style=""></span>min longer in the case of robotic surgery, although blood loss in this group was lower. Morbidity and mortality and the number of dissected lymph nodes per level were comparable between the two techniques.<a class="elsevierStyleCrossRef" href="#bib0205"><span class="elsevierStyleSup">16</span></a></p><p id="par0075" class="elsevierStylePara elsevierViewall">Considering the complexity of pancreaticoduodenectomy, robot-assisted surgery could be a way to increase minimally invasive surgery procedures. Robotic surgery is a feasible and safe technique for this type of procedures.<a class="elsevierStyleCrossRef" href="#bib0210"><span class="elsevierStyleSup">17</span></a> Preliminary comparisons with open surgery<a class="elsevierStyleCrossRef" href="#bib0215"><span class="elsevierStyleSup">18</span></a> indicate a shorter operating time, less blood loss and a greater number of resected lymph nodes in favour of robotic surgery. A meta-analysis<a class="elsevierStyleCrossRef" href="#bib0220"><span class="elsevierStyleSup">19</span></a> which included 6 studies showed a higher rate of R0 radical resections in the robotic group. The surgeons perception was that the robot made complicated surgery steps easier, such as dissection and reconstruction.<a class="elsevierStyleCrossRef" href="#bib0225"><span class="elsevierStyleSup">20</span></a> The distal pancreatectomy with splenic preservation seems to be an indication of robot-assisted surgery, obtaining better oncology results in preliminary studies.<a class="elsevierStyleCrossRef" href="#bib0230"><span class="elsevierStyleSup">21</span></a></p><p id="par0080" class="elsevierStylePara elsevierViewall">Robot-assisted liver surgery simplifies hepatic pedicle dissection and biliary reconstruction, which are 2 technically difficult steps in laparoscopic surgery, although there are only around 100 cases of liver resections described in medical literature.</p><p id="par0085" class="elsevierStylePara elsevierViewall">A systematic review of colonic resections, including case series and comparative studies showed no benefit of robotic surgery when compared to laparoscopic surgery, neither in malignant nor in benign disease. Regarding rectal surgery, there is evidence that robotics reduces the rate of conversion to open surgery, with no differences in regard to surgery time, morbidity, hospital stay and oncological results.<a class="elsevierStyleCrossRefs" href="#bib0235"><span class="elsevierStyleSup">22,23</span></a> Both, the magnified 3D vision and the skill of robot movements help with nerve preservation during total mesorectal excision, leading to faster recovery of both, sexual and urinary function.<a class="elsevierStyleCrossRef" href="#bib0245"><span class="elsevierStyleSup">24</span></a></p><p id="par0090" class="elsevierStylePara elsevierViewall">Although the future is uncertain in many aspects of life, when it comes to robotic surgery it does not seem to be the case. Each day new features and models continue to improve existing robotic systems. The <span class="elsevierStyleItalic">Technische Universiteit Eindhoven</span> researcher, Linda van den Bedem, published a report in <span class="elsevierStyleItalic">ScienceDaily</span> on the development of a more compact surgical robot called Sofie, which uses force feedback to give the surgeon a more real perception (feeling) of what is really happening.<a class="elsevierStyleCrossRef" href="#bib0250"><span class="elsevierStyleSup">25</span></a> Another aspect that has been investigated is the possibility of controlling robotic surgery systems using artificial intelligence. In 2010 several bioengineers of the <span class="elsevierStyleItalic">Duke University</span> demonstrated that a robot is able to locate a lesion in simulated human organs without human help and guide a device to the lesion and take multiple samples from that location during a single session (<span class="elsevierStyleItalic">Duke Robot Biopsy Guided by 3-D Ultrasound</span>). However, this race is not over yet, since there are still many challenges ahead, the next step being the use of nanorobots. These are robots the size of a cell, which can be introduced into the bloodstream to kill cancer cells, repair tissues or capture toxic radicals, all guided by remote control.</p><p id="par0095" class="elsevierStylePara elsevierViewall">The results so far are positive and it seems that it is only a matter of time that robotic surgery will become the reference procedure for a number of surgical interventions.</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Conflict of interests</span><p id="par0100" class="elsevierStylePara elsevierViewall">The authors declare no conflict of interest.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:2 [ 0 => array:2 [ "identificador" => "sec0005" "titulo" => "Conflict of interests" ] 1 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2015-04-07" "fechaAceptado" => "2015-04-09" "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Bravo R, Lacy AM. Medicina y robótica. Med Clin (Barc). 2015;145:493–495.</p>" ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:25 [ 0 => array:3 [ "identificador" => "bib0130" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Cirugía robótica" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:5 [ 0 => "L. Moreno-Portillo" 1 => "C. Valenzuela-Salazar" 2 => "C. David Quiroz-Guadarrama" 3 => "C. Pachecho-Gahbler" 4 => "M. 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