General Surgery In the Digital Age

Transcription

1 General Surgery In the Digital Age Stanley Rogers, MD Associate Clinical Professor of Surgery Ruth M. Dunn Chair and Chief, Minimally Invasive Surgery Director, Bariatric Surgery University of California, San Francisco UCSF Post Graduate Course in General Surgery Wednesday, March 28, 2012 Array of Potential Uses of Digital Systems Medical Imaging, e.g. CT, MR, US, SPECT, PET, DR, Molecular Imaging, and Virtual Endoscopy Image Processing and Display 3D, 4D and 5D Imaging Hospital Wide PACS and Telemedicine Computer Applications for e.g. Neurosurgery, Head and Neck, Orthopaedics, Ear Nose and Throat, Cardiovascular and Thoracoabdominal Surgery, and Plastic/Reconstructive Surgery Image Guided Therapy Surgical Robotics and Instrumentation Surgical Navigation 3D Modelling and Rapid Prototyping Postoperative Result Assessment Surgical Education and Training Haptics and Multimodal Devices in Medical Applications Methods of Validation and Verification CAD for Breast, Prostate, Chest, Colon, Skeletal, Liver, Brain and Vascular Imaging Cranial and Maxillofacial Image Guided Surgery Surgical Workflow Surgical DICOM and IHE Digital Operating Room Array of Potential Uses of Digital Systems Image Guidance Medical Imaging, e.g. CT, MR, US, SPECT, PET, DR, Molecular Imaging, and Virtual Endoscopy Image Processing and Display 3D, 4D and 5D Imaging Hospital Wide PACS and Telemedicine Computer Applications for e.g. Neurosurgery, Head and Neck, Orthopaedics, Ear Nose and Throat, Cardiovascular and Thoracoabdominal Surgery, and Plastic/Reconstructive Surgery Image Guided Therapy Surgical Robotics & Instrumentation Surgical Navigation 3D Modelling and Rapid Prototyping Postoperative Result Assessment Surgical Education and Training Haptics and Multimodal Devices in Medical Applications Methods of Validation and Verification CAD for Breast, Prostate, Chest, Colon, Skeletal, Liver, Brain and Vascular Imaging Cranial and Maxillofacial Image Guided Surgery Surgical Workflow Surgical DICOM and IHE Digital Operating Room Integration advanced imaging technology image processing 3D graphical capabilities image guided and computer-aided surgery Navigation in surgery ability to locate a given point using geometric reference based on stereotactic principles. 1

2 Image Guidance in Liver Surgery Image Guidance in Liver Surgery The real-time VR navigation system utilizing an open MRI operating theatre allows dynamic accurate percutaneous access to liver tumors, especially tumors that cannot be adequately visualized by US Image Guidance in Liver Surgery Registration between dynamic real-time US imaging & pretherapeutic MR data - real-time images are integrated and displayed by 3D-Slicer. Percutaneous puncture performed with dynamic customized 3DSlicer navigation. Image Guidance: Liver Surgery Planning 2

3 Image Guidance: Liver Surgery Planning Image Guidance in Liver Surgery Evaluated impact of simulated surgery using image data from multidetector CT scanning on planning & performing laparoscopic hepatectomy Hepatectomy simulation system program Digital 3-D reconstruction of hepatic vasculature calculate liver resection volume and surgical margin. 35 patients undergoing laparoscopic hepatectomy or laparoscopyassisted hepatectomy Liver resection volume & margin were estimated by simulation preoperatively. Estimated values were compared with the actual resected liver weight and margin. 3D reconstruction allowed stereoscopic identification of the tumor-bearing portal vein and draining vein. Image Guidance: Liver Surgery Planning Image Guidance in Liver Surgery Results Accurately predicted liver resection volume and margin 3D imaging calculations were significantly correlated with the actual pathologic values mean difference 21 ml (P\0.0001) and 1.3 mm (P\0.01), respectively. 3D simulation of hepatectomy facilitated intraoperative identification of the vascular anatomy, accurately predicted the resected liver volume and surgical margin. Simulation method can contribute to preoperative planning for safer and more accurate laparoscopic hepatectomy Preoperative planning based on simulated resection facilitated laparoscopic liver mobilization resection of a large tumor located in the upper right lobe. 3

4 Image Guidance in Liver Surgery Virtual Reality Definition Computer based training system Virtual environment Navigation Interaction Real time Virtual Reality Why is VR Simulation necessary Anxiety by lay persons because surgeons learn on patients Simulators offer the prospect of learning outside the OR Supervisor can assess trainee progress independently Virtual Reality a. CT scan demonstrating a 3-cm left adrenal mass; b. its VR reconstruction 4

5 Virtual Reality best viewed on a computer monitor screen still pictures show how a virtual environment can be created where complex structures are represented in full 3-D surgeon has ability to interact with the images understand the anatomy of a structure, features of a lesion, & trelationship with different organs & vessels Virtual Reality Virtual Reality VR allows the use of virtual transparency of organs and vessels and, importantly, the intraluminal navigation in hollow organs or vessels. Virtual Reality Concept of virtual laparoscopy - abdominal organs / skin: reconstructed from CT scan. Virtual laparoscope - inserted & internal view shown - could be used to replace laparoscopic diagnostic explorations or to perform surgical planning. 5

6 Virtual Reality (laparoscopy) Trocar position planning: VR reconstruction software - allows placement of virtual patient in lateral decubitus position, & placement of a virtual laparoscope and instruments in desired position Virtual Reality (laparoscopy) Trocar position planning: smaller windows on the left show inside view & allow planning of ideal angulation between dissecting instruments & anticipate possible conflicts. Virtual Reality (laparoscopy) Once most suitable position chosen - software calculates distance (ie. in centimeters) from ribs & between trocars. This is a preliminary step in the performance of simulated laparoscopic adrenalectomy / surgery. Integrating Surgical Systems for Autonomy The Operating Room (personnel) of the Future 100,000 Surgeon Assistant Scrub Nurse Circulating nurse Borrowing from the standard practices of other industries 6

7 Operating Room with no People Digital Operating Room Robotic Surgery Definition of a Robot Machine that resembles a human and does mechanical, routine tasks on command Any mechanical device that operates automatically with human-like skill A robot is not a machine.it is an information system with arms 7

8 Robots: Better Than Humans? Robots: Better Than Humans? Robotic Surgery History: Companies & Systems Robotic Surgery History: Companies & Systems First Robotic assisted surgery 1988 PUMA 560 Light duty industrial robotic arm to guide laser/needle for sterostactic brain surgery First commercially available robotic system, 1992 ROBODOC for orthopaedic hip surgery 8

9 Robotic Surgery History: Companies & Systems Surgical Robots in 2007 First Robotic urological surgery 1992 PROBOT-assisted TURP in Guy s Hospital in London leaded by Wickham AESOP (Automated Endoscopic System for Optimal Positioning) - Voice activated mechanical arm - Steadier than human, never tires davinci - FDA approval in Laparoscopic instrumentation controlled by the surgeon positioned remotely at a console Development of davinci Defense Advanced Research Projects Agency (DARPA) for military research of remote battlefield surgery Cholecystectomy performed remotely via telesurgery from 300 miles away Intuitive Surgical created in 1999 after acquiring patent rights from military First robotic prostatectomy performed in 2001 Robotic Surgery History: Companies & Systems First RCT of transatlantic telerobotics surgery Between Guy s and John Hopkins Hospitals PAKY-RCM percutaneous access robot (Kavoussi group developed in 1996) 9

10 Design of Robotic Telesurgery Minimally Invasive Surgery Surgery performed by making small incisions < 10mm dia Reduces post-operative pain and hospital stays Form of telemanipulation Instruments have a camera attached to transmit inside image to the surgeon Design of Robotic Telesurgery The Concept Telerobotics is a natural tool to extend capabilities in MIS The goal is to restore the manipulation and sensation capabilities of the surgeon Using a 6 DOF slave manipulator, controlled through a spatially consistent and intuitive master Design of Robotic Telesurgery The Concept Telesurgical system concept Design of Robotic Telesurgery Considerations: Compatibility Backdrivabilit Actuator s impedance Actuators receive tool-to-tissue force Loss of power can lead to dropping of a heavy tool and undesirable high accelerations in the actuator 10

11 Operation Lindberg : Remote Transatlantic Telesurgery AESOP (Computer Motion), 1994 Automated Endoscopic System for Optimal Positioning a voice-activated robotic arm for camera holder First approved surgical robotic system by FDA AESOP ZEUS (Computer Motion) Marketed in

12 Da Vinci (Intuitive Surgical) Initially developed by US Department of Defence in 1991 Intuitive Surgical acquired the prototype and commercialized the system Approved by FDA in July 2000 Da Vinci Surgical system by Intuitive Surgical, Inc. Da Vinci Surgical system by Intuitive Surgical, Inc. Surgical Console - 3D display and master control Patient side cart - two or three instrument arms and one endoscope arm EndoWrist Instrument - 7 DOFs, quick-release levers InSite Vision System - high resolution 3D endoscope and image processing equipment Da Vinci Surgical system by Intuitive Surgical, Inc. 12

13 Da Vinci Surgical system by Intuitive Surgical, Inc. Da Vinci Surgical system by Intuitive Surgical, Inc. davinci Surgical System U.S. Installed Base Da Vinci surgical system in a general procedure setting 13

14 Advantages: Robotic Surgery Strengths & Limitations Strengths: Physical separation Wrist action Tremor elimination Optional motion scaling Three-dimensional stereoscopic image Electronic information transfer (Telesurgery) Robotic Surgery Strengths & Limitations Robotic Surgery Strengths & Limitations Limitation Reluctance to accept this technology (trust) Additional training Fail proof? Most of the sensors use IR transmission Highly efficient visual instruments are needed Cannot be pre-programmed Task-specific robots are required Latency in transmission of mechanical movements by the surgeon Longer operating time EXPENSE Limitation Costs for the Da Vinci system: The average base cost of a System is $1.5 million Approximately $ 160,000 maintenance cost a year Operating room cost, $150 per hour Hospital stay cost, $600 per day Time away from work, $120 per day 14

15 Robotic Surgery Ethical / Safety Considerations Robotic Surgery Challenges & Future When there is a marginal benefit from using robots, is it ethical to impose financial burden on patients or medical systems? If a robot-assisted surgery fails because of technical problems, is it the surgeon who is responsible or others? Haptic feedback A safe, easy sterilizable, accurate, cheap and compact robot Reliable telesurgical capabilities Compatibility with available medical equipment and standardizing Autonomous robot surgeons Current Applications Versatility in General Surgical Applications Bariatrics Roux-en-Y Gastric Bypass, Gastric Banding, Biliopancreatic Diversion Colon/Small Bowel Esophageal/ Foregut Hemicolectomy, Sigmoid Colectomy, Ileocectomy, Abdominalperineal resections, Low Anterior Resection, Small Bowel Stricturoplasties Heller myotomies, Nissens, Gastric Resections, Gastric Pacing Wires, Esophagectomies (Transhiatal or Transthoracic), Hepatobiliary/p ancreatic Lobectomies, Segmentectomies, Choledochal-jejunostomy, CBD Exploration, Distal Pancreatectomy, Whipple, Ampullectomy Other Live donor nephrectomies, adrenalectomy, Hernias Splenectomy, Aortofemoral Bypass, AAA 15

16 da Vinci Heller Myotomy Comparison of Laparoscopic and da Vinci Heller Myotomy *Sharp KW, et al. 100 consecutive minimally invasive Heller myotomies: lessons learned. Ann Surg 235(5): , 2007 **Santiago Horgan, M.D. University of Illinois, Chicago data used *the values for the reference standard (open RP) were considered the index value, with values in each row (n) referenced to the index value Robotic vs. Laparoscopic Adrenalectomy Robotic vs. Laparoscopic Adrenalectomy Karabulut et al., Surgery 2012;151: Karabulut et al., Surgery 2012;151: consecutive laparoscopic cases lateral transabdominal (LT) approach: 32 posterior retroperitoneal (PR) approach: 18 Prospective, IRB-approved database Robotic case data compared with 50 consecutive laparoscopic cases (LT = 32, PR = 18) before start robotic program. No difference regarding demographics, tumor type, and body mass index LT approach: operative times were similar (168 ± 10 minutes vs 159 ± 8 minutes, P =.5) despite larger tumor size (x ± SEM) in the robotic vs the laparoscopic group (4.7 ± 0.4 vs 3.8 ± 0.4 cm, P =.05) No difference between regarding the time spent on individual steps of the operation. PR approach, with similar tumor sizes (2.7 ± 0.3 cm vs 2.3 ± 0.3 cm, P =.4), operative time (minutes) was equivalent (166 ± 9 vs 170 ± 15; P =.8). Time spent intra-operatively for each step was similar, except for shorter hemostasis time in the robotic group (23 ± 4 minutes vs 42 ± 9 minutes, P =.03). 16

17 Robotic vs. Laparoscopic Adrenalectomy Robotic vs. Laparoscopic Adrenalectomy Karabulut et al., Surgery 2012;151: Karabulut et al., Surgery 2012;151: The robotic docking time (21 vs 25 minutes) decreased by 50% in the second year of the study for both approaches. The presence of two staff surgeons vs a staff and a fellow decreased operative time for the robotic LT (P<.02) but not the robotic PR approach. For laparoscopic and robotic procedures, the morbidity was 10% and 2%, respectively. Overall, hospital stay was 1.5 ± 0.9 days (range, 1 4 vs 1.1 ± 0.3 days) (range, 1 2; P =.006). The percentage of patients requiring more than 1 day of hospital stay was 28% vs 14% (P =.09). Intraoperative time analysis - time use was similar between the laparoscopic and robotic groups for both LT and PR approaches. However, the morbidity was less and hospital stay was shorter with the robotic procedures Robotic Surgery: other procedures Robotic Liver Surgery Splenectomy Total gastrectomy Lung lobectomy Colorectal surgery Thyroidectomy Adrenalectomy Esophagectomy Major hepatectomies CBD Procedures Whipple 1992 First laparoscopic liver resection Gagner et al. Surg Endosc 1992; 6: First anatomic laparoscopic liver resection Azagra et al. Surg Endosc 1996; 10: First laparoscopic major liver resection Huscher et al. J R Coll Surg Edinb 1997; 42:

18 Robotic Liver Surgery Robotic Liver Surgery In the current literature, only few small robotic series Good clinical results Robotic facilitate liver resection Especially for procedures that require a small operating field Left lateral sectionectomy is the first step in the learning curve Giulianotti PC et al. Arch Surg 2003;138: Patriti A et al. J Hepatobiliary Pancreat Surg 2009;16: Tomulescu V et al. Chirurgia (Bucur) 2009;104: Vasile S et al. Chirurgia (Bucur) 2008;103: Choi SB et al. Yonsei Med J 2008;49: Giulianotti PC et al. Surgery 2010; Jun 4. Surgery 2010; June 4 Robotic Liver Surgery Robotic Liver Surgery 100 Robotic Liver resections 49 males and 51 females Mean age 56.2 yrs (range 20 84) Currently acceptable indications: solitary lesions, 5 cm or less, located in liver segments 2 to 6 Hepatic lesions localization Major liver resections should be reserved for experienced surgeons Conversion should not be considered as a failure Utilization of a hand assist or hybrid technique may be faster and safer Laparoscopic liver surgery has not been tested by controlled trials for efficacy or safety A prospective randomized trial appears to be logistically prohibitive An international registry should be initiated to document the role and safety of laparoscopic liver resection. VI VII V 10 VIII 6 IV III II

19 Robotic Liver Surgery Major Hepatectomies: 38 Right hepatectomy 29 pts Left hepatectomy 7 pts Right trisectionectomy + Biliary reconstruction 2 pts RESULTS Robotic Liver Surgery MAJOR HEPATECTOMIES Mean Operative time: min ( ) MINOR RESECTIONS Mean Operative time: min (45-579) Minor Resections: 62 Segmentectomy 19 pts Bisegmentectomy 18 pts Left lateral sectionectomy 11 pts Non Anatomical 14 pts Mortality: NO MORTALITY Conversion: 11% Transfusions: 10% (majority cirrhotic patients) Only one Pringle maneuver Morbidity: 16% Length of stay: 7 days (5 days in US) Giulianotti PC et al. Surgery 2010; Jun 4. Giulianotti PC et al. Surgery 2010; Jun 4. Robotic Liver Surgery Robotic Liver Surgery Robotic surgery is safe and feasible in experienced hands The technical abilities of the robotic system might improve the critical steps of minimally invasive major liver resections Robotic surgery may expand the indications for minimally invasive liver surgery For oncology, robotic surgery is one of the tool to extend the limit of minimally invasive surgery in the field of liver resections Probably achieves the same oncological results as open approach Achieves low morbidity and mortality rate Expands the possibilities of minimally invasive surgery Giulianotti PC et al. Surgery 2010; Jun 4. Giulianotti PC et al. Surgery 2010; Jun 4. 19

20 Robotic Surgery: Pancreas Pancreas Nov 12. Robotic and Laparoscopic Pancreaticoduodenectomy: A Hybrid Approach. Narula VK et al. 5 patients Laparoscopic dissection Robot-assisted reconstruction: pancreaticojejunostomy and choledocojejunostomy Mean operative time: 420 minutes Mean hospital stay: 9.6 days At 6 months: all patients were disease-free. Complex procedures such as PD can be accomplished with minimally invasive surgical techniques using robotic instrumentation. Robotic Surgery: Pancreas Morbidity: 26% Mortality: 2.2% Conversion Rate: 10.4% Fistula Rate: 20.9% 134 pancreatic procedures Robotic surgery enables difficult technical maneuvers to be performed that facilitate the success of pancreatic minimally invasive surgery. The results in this series demonstrate that it is feasible and safe. Robotic Surgery: Pancreas Robotic Surgery: Future Applications Advanced Endoscopy 20

21 Natural Orifice Surgery Peroral Transgastric Endoscopic Surgery Natural Orifice Transluminal Endoscopic Surgery (NOTES) Courtesy of N Reddy, Hyperbad India Courtesy of N Reddy, Hyperbad India Trans-gastric Appendectomy Climbing the Learning Curve Standard surgery: see one, do one, teach one Robotic surgery: see one, do one, kill one Requires entirely new skill set beyond traditional surgical and laparoscopic training Training opportunities limited Animal labs helpful Cases require outside proctor to determine competency Credentialing challenges?? 21

22 Surgical Simulation Education / Credentialling Surgical Skills Assessment Robotic Rounding Robotic Scrub Nurse Penelope 22

23 Robotic Scrub Nurse Operating Room of the Future Conclusions The rate of discovery of new technology is outpacing the ability of business, society, and healthcare to integrate and apply Digital surgery shows that technology can reduce operative morbidity, hospital stay, and recovery, while potentially improving clinical outcomes but at what point do the BENEFITS have to justify the EXPENSE? Mahalo 23