Over the years, there have been a handful of pivotal events that have
truly brought about fundamental change in the way surgery is performed:
the discovery of anesthesia by Clarke in 1846; the introduction of
sterile technique by Semmelweis, Pastuer, and ultimately Lister in 1867;
the development of the heart lung machine by Gibbon in 1931. These are
just a few high profile examples of discoveries that have made modern
day surgery possible. Conventional laparoscopic surgery and robotic
laparoscopic surgery are two more recent developments that have
profoundly influenced the way many operations are done, but to
understand their importance, they must be contrasted with traditional
“open” surgery.
“Open” abdominal surgery (fig. 1) is accomplished by making an incision
through the abdominal wall that is large enough to provide the surgeon
Figure 1
with: a direct three dimensional view of the operative site (because we
normally view the world in 3-D), the ability to feel the structures
being operated on, and unrestricted access to the patient’s anatomy so
the surgeon can use his/her wrists (very important) to accurately
position and use a wide array of surgical instruments inside the
patient. As a result, the open approach to surgery offers the surgeon
the ability to perform a wide variety of complex and challenging
maneuvers, and prior to 1989 was essentially the only surgical approach
available for performing abdominal operations.
However, patients “pay a price” for these large abdominal incisions. The
majority of pain that is experienced from an abdominal operation does
not actually come from what is done to the diseased structure inside the
patient (whether that is the gallbladder, the colon, etc), but from the
incision the surgeon makes through the layers of tissues and muscles of
the abdominal wall to reach the diseased structure. In general, the
longer the incision and the more muscle tissue that is disrupted, the
more postoperative pain the patient experiences and the longer it takes
to recover. In addition, any incision heals with a scar. The visible
scar on the outside has only cosmetic implications, but that same
scarring also occurs inside the abdomen, producing what are commonly
called adhesions. These adhesions can allow the intestines to twist,
producing a bowel obstruction. Adhesions also increase the technical
difficulty involved in performing any future abdominal operation should
one be required for a different disease process. Minimizing these
problems whenever possible had therefore long been a goal, not attained
until the advent of video laparoscopic surgery.
In 1901 George Kelling was the first physician to actually look inside
the abdomen without making a large incision. Known as laparoscopy, he
viewed the abdomen through a simple hollow tube. (fig. 2)
Figure 2
Bernheim introduced this procedure to the United States in 1911, but
visualization was so limited that virtually nothing of significance was
done with this technique. Then, in 1951 Hopkins developed an optical
telescope to replace Kelling’s simple hollow tube. (fig. 3) This
telescope represented a major advance over Kelling’s simple tube. It was
slightly less than half inch in diameter and could also be introduced
Figure 3
into the abdomen through a small puncture rather than through a large
incision. However, visualization through it still remained very limited
because under normal circumstances the entire abdominal cavity is filled
with structures that all touch each other, leaving virtually no space
inside the abdomen to visualize anything. Then in 1967 Semm invented a
device (the automatic insufflator) that allowed the abdominal cavity to
be filled with gas, creating visual space inside the abdomen by gently
pushing structures away from each other (notice how the abdomen in
figure 4 is “distended with gas”). With the abdomen insufflated,
Figure 4
Hopkins’ telescope (laparoscope) provided an unparalleled view of
structures inside the abdomen. This telescope and Semm’s insufflator
remain in use essentially unchanged to this day. However, this
laparoscope was initially a one hand, one person device. (fig. 4) To
perform direct vision laparoscopy, the surgeon had to hold the telescope
with one hand leaving just one hand with which to operate. And since
only one person at a time could view the operative site through this
device, no one could actually assist the surgeon. Direct vision
laparoscopy was therefore limited primarily to diagnostic use. Then in
1982 the high definition color video camera was miniaturized. In 1987 it
was connected to the Hopkins’ laparoscope (fig. 5) and the modern age of
Figure 5
video-laparoscopy was born. This allowed a video image from inside the
abdomen to be projected onto a television monitor in the operating room.
(fig. 6) The surgeon could now operate standing upright instead of
bending over the patient and just as importantly everyone in the
operating room could see exactly what the surgeon could see. This
enabled an assistant surgeon to pass instruments into the abdomen
through additional small tubes (called “ports”) and participate in the
operation. With this development, Mouret was able to complete the first
laparoscopic cholecystectomy (removal of the gallbladder) in France in
Figure 6
1987.
Even so, it became immediately apparent that operating from a video
image through small punctures in the abdominal wall instead of through
the traditional large open incision presents its own challenges. The
surgeon’s hands are now located outside of the patient (fig. 6 & fig. 7)
more than a foot away from the operative site (so there is no longer the
natural touch and feel of the tissue associated with open surgery); the
video image is 2-dimensional (rather than our normal 3-dimensional
vision); and the instruments need to be inserted through small
Figure 7
punctures to reach the disease structure, so they are long, rigid, and
most significantly, they are “un-wristed” (fig. 8) All of these
limitations severely restrict the surgeon’s access to the anatomy and
make complex surgical maneuvers (such as suturing) more difficult to
accomplish. Despite these significant drawbacks, a few of us started
Figure 8
utilizing this technique initially to remove the gallbladder because
this operation required relatively uncomplicated surgical maneuvers.
This approach changed a painful “open” operation to a much less invasive
one with less postoperative pain, less scaring, and a much faster
recovery. The benefit to the patient proved to be so obvious and so
significant that patient demand for the laparoscopic cholecystectomy
established it as the standard of care in this country within three
short years. Very soon thereafter, appendectomies and inguinal hernia
repairs were also being done routinely with the laparoscope. But as time
passed, it became evident that the majority of general surgeons found
applying the laparoscopic approach to the more complex or advanced
procedures either too limiting or simply too difficult for them to
master. Clearly additional innovation would be needed if a minimally
invasive surgical approach to more complex procedures was to be used by
the majority of surgeons, rather than just by the minority of us who had
pioneered the laparoscopic surgical approach.
An approach was needed to restore to the surgeon the capabilities of
open surgery while maintaining the patient benefits of laparoscopic
surgery. To accomplish that, three problems needed to be solved:
- unrestricted movements (i.e., wrist-like movements) and precise control of instruments inside the patient needed to be restored
-
a high resolution 3-dimensional image needed to be provided to the
surgeon
-
and to the extent possible, the natural touch and feel of the tissue inside the abdomen should be returned to the surgeon, including giving control of the tip of the instrument back to the surgeon
Figure 9
This was accomplished in 1998 by Intuitive Surgical, Inc. with the
development of a “robot” known as the da Vinci® Surgical System. I was
asked by Dr. Fred Moll, the co-founder of Intuitive Surgical, to serve
as the company’s primary clinical consultant and principal investigator
during the design phase and development of this system. As a result I
bring a unique perspective on what was involved in developing this
device and why it took the form that it did.
Figure 10
We designed the da Vinci® System with three parts: a work
station (or surgeon’s console), a patient side cart, and a computer
connecting the two together. (fig. 9) The surgeon’s console (fig. 10)
contains the computer, the “handles” for two laparoscopic instruments, a foot mechanism to control movements
of the camera, and a magnified 3-dimensional image of the operative site projected over the surgeon’s hands. (fig. 11)
The latter provides the surgeon with the most realistic
representation possible of the patient’s anatomy. (left side of fig. 11)
Figure 11
The patient side cart contains four motor driven mechanical arms (fig.
12) holding the camera and the instruments that are actually
introduced into the patient. Rather than the rigid, straight instruments
used in conventional laparoscopy (fig. 13), da Vinci® instruments are
fitted with articulated “wrist” joints at the point of use inside the
Figure 12
patient. (fig. 14) Even though this device has been termed a
“robot”, it makes no movements on its own. Rather, the computer
instantly translates movements made by the surgeon at the console into
Figure 13
precisely the same movements of the instruments inside the patient.
Without this computer interface between the surgeon at the console and
the patient side cart, control of the da Vinci® instruments with
articulated wrists would be impossible. (fig. 14) The computer also
measures the forces encountered by the tips of the instruments inside
the patient and feeds those forces back to the surgeon’s hands at the
console re-establishing the “feel” of actual surgery. The da Vinci
Surgical System® provides the surgeon with unparalleled dexterity,
precision, and control and restores nearly unrestricted freedom of
movement of these articulated instruments inside the patient.
Figure 14
The creation of this robotic system thus removed most if not all of the physical limitations placed
on the surgeon by conventional laparoscopic surgery. This has resulted in
two very significant advances in surgical practice. In the hands of surgeons skilled in its
use, it not only
enables laparoscopic techniques to be used in more complex abdominal procedures
(ones that typically have been done and many times are still being done with open surgery), but in
some operations it allows us to
actually improve upon traditional open surgical techniques as well.
Which one of these three surgical approaches is most appropriate for any
given patient will depend on his/her specific circumstances.
Fortunately, the vast majority of
abdominal surgeries can now be
accomplished with either a laparoscopic or robotic laparoscopic approach
if the surgeon is experienced with and credentialed in using those
approaches by his/her hospital.
[Note: a few centers (mostly outside the
United States) are experimenting with robotic techniques for
non-abdominal cavity operations on structures such as the thyroid and
the breast. Trying to apply either robotic or videoscopic techniques to
these procedures makes an otherwise very straight-forward operation
highly complex, and in my opinion, does not currently provide added
benefit to the patient.]
These are the approaches to specific conditions that I recommend most
often in my surgical practice:
- Cholecystectomy, appendectomy, inguinal hernia repair, and most colon
resections are perfectly suited to conventional laparoscopic surgery.
These procedures are relatively straight forward and are actually made
more complicated by use of the robot. So, absent unusual or unforeseen
circumstances, I do not ordinarily need to recommend either open surgery
or the da Vinci® Surgical System for these procedures.
- Robotic laparoscopic surgery is an excellent choice for the vast
majority of remaining abdominal procedures, especially those that
require much suturing. This includes most operations for GERD (gastroesophageal
reflux disease), repair of hiatal hernias, and operations on the
stomach, small intestine, lower part of the colon, and rectum. It also
includes surgery on solid organs such as the spleen, body or tail of the
pancreas, or removal of the adrenal glands. Perhaps most significantly,
the da Vinci® system is particularly well suited for repairing hernias
of the abdominal wall (either epigastric, umbilical or incisional hernia). Using the robot for repairing these specific hernias results
in the best possible placement of the mesh, the lowest incidence of
recurrence, and significantly less postoperative pain.
- There are some highly complex and very extensive procedures (such as
major liver resections) that have been done with the da Vinci® Surgical
System in very selected circumstances, but procedures of this magnitude
are usually best accomplished with open surgery.
To summarize then, in my opinion most general surgical procedures within
the abdominal cavity are best done either with a conventional
laparoscopic or a robotic laparoscopic approach because of the obvious
benefits afforded to the patient with these minimally invasive
techniques. General surgery procedures for structures that are
not in
the abdominal cavity (such as procedures on the thyroid, breast, and
skin) are generally
not enhanced by utilizing a laparoscopic approach,
and are therefore discussed separately.
