The last three decades in the surgical world have been defined by an explosion in the number and type of procedures performed by minimally invasive surgery. This drive has been enabled by the sustained development of a wide array of innovative medical devices, from trocars and endoscopes to tissue approximation devices such as neoClose (neoSurgical, Galway, Ireland) and clip applicators such as Endo Clip (Covidien, North Haven, CT). The emergence of the surgical robot in recent years has had a dramatic impact on minimal access surgery, raising the bar in terms of technological advancement. To date, however, the introduction of novel devices designed specifically for use with robotic surgery has lagged behind the development of instruments for conventional laparoscopy.
The da Vinci Surgical System (Intuitive Surgical Inc, Sunnyvale, CA) has been at the forefront of robotic surgery since its clearance by the FDA in 2000. This breakthrough technology offers a number of advantages over conventional laparoscopy including 3D visualization, greater dexterity, physiologic tremor filtration and improved ergonomics (1). The da Vinci camera platform also restores natural hand-eye coordination, making instrument manipulation more intuitive (1). These impressive developments allow the surgeon to perform more precise dissections and anastomoses which are not feasible with conventional laparoscopic instruments.
There has been a marked increase in the volume of robot-assisted procedures performed over the last number of years. The number of robotic procedures nearly tripled between 2007 and 2009, from 80,000 to 205,000 (2). Intuitive Surgical reported a further increase in 2010, with 278,000 da Vinci procedures being performed. To ensure that this escalation continues into the future, convergence of robotic systems with the latest technological advances in conventional laparoscopy will be required. Laparoscopic devices that are customized for the surgical robot will be necessary to ensure low complication rates while also facilitating shorter procedural times. This technological convergence will likely establish robot-assisted surgery as the standard of care for a broader spectrum of patients and procedures, expanding the scope of minimal access surgery.
In addition to the well-documented benefits of minimally invasive surgery, there are also a small number of complications. One of these is port site herniation, which can lead to morbidity due to small bowel strangulation (3). An important risk factor for herniation is trocar size, with a consensus that all ports of 10 mm or greater should be closed (3,4). Smaller ports should also be closed if they have been subjected to extensive manipulation (4). Compared with conventional laparoscopy, robotic surgery has resulted in an increase in the number and size of ports required for some procedures, such as gynecologic laparoscopy (5,6). Additionally, increased manipulation of ports is often necessary. Combined with the extended oblique positioning of ports which is facilitated by the robotic platform, this can lead to enlargement of port sites. These factors have led to the concern that an increased port site hernia rate may be introduced. Fascial closure at da Vinci 5 mm and 8 mm trocar sites should therefore be considered where extensive manipulation or extended oblique positioning of trocars has occurred, while the 12 mm camera port should always be closed.
Pediatric surgery is expected to benefit substantially from the surgical robot, since the technological advantages are particularly significant when working on the small anatomic structures of children. A recent systematic review of pediatric robotic surgery covering the period from 2001 to 2012 indicated an overall trend of increasing volumes and an increase in the complexity of procedures being reported over time (7). With the likelihood that this trend will continue, an effective method of port closure is required for use with da Vinci trocars in the pediatric population. Closure of all da Vinci trocar sites will safeguard against the increased risk of herniation in children due to weakness of the abdominal wall muscles and the smaller size of the bowel and anatomic structures (8,9).
Bariatric surgery, particularly Roux-en-Y gastric bypass, has also been highlighted as an area that is likely to benefit significantly from the use of robotic systems (10,11). This is due to increased dexterity which facilitates intracorporeal suturing for intestinal anastomoses. Robotically sutured anastomoses are suggested to have a lower leak rate compared with anastomoses stapled laparoscopically (10,11). The robotic approach is also associated with a shorter hospital stay compared with laparoscopic Roux-en-Y gastric bypass (10). Since high BMI has been established as a risk factor for port site herniation (12,13), fascial closure of all da Vinci port sites should be considered in the bariatric population. This will help to maintain complication rates at a minimal level as the number of robotic bariatric procedures increases in the future.
Due to the requirements for fascial closure during robotic surgery, there is an unmet clinical need for an effective and quick method of closing the fascia at da Vinci 12 mm, 8 mm and 5 mm trocars. This closure method must be suitable for use in pediatric and bariatric populations. One device which is currently being used for port site approximation in conventional laparoscopy is neoClose.
Such a device, customized for use with the surgical robot, may provide a solution to this unmet need.
Robotic surgery currently has a high capital cost, with installation of the da Vinci System having a price tag in excess of $1 million. Despite this sizeable outlay, its cost-effectiveness has been established for a number of procedure types (10,14,15). Indeed, the overall cost of robotic Roux-en-Y gastric bypass is substantially lower than its laparoscopic counterpart in high-volume centers, due to lower anastomotic leak rates, shorter hospital stays and a reduction in laparoscopic staplers being used (10). Within the last five years, numerous patents for robotic surgical systems and accessories have been filed by several companies including Samsung, LG, Terumo and Siemens. Increased competition in what has been a largely monopolized market to date is expected to drive capital costs down and promote a sweeping adoption of this technology.
With the expectation of a sharp rise in the volume of robot-assisted procedures in the future, it is likely that the complexity of cases being performed robotically will increase. The availability of a greater range of instruments, accessories, and medical devices customized for use with robot systems will facilitate this shift in approach. Such devices will ensure that the technological advantages of the robot facilitate consistent positive outcomes for the patient. Technological convergence with the latest advances in conventional laparoscopy will promote a paradigm leap in the OR, defining the next phase of minimally invasive surgery.
1. Lanfranco AR, Castellanos AE, Desai JP, Meyers WC. Robotic surgery: a current perspective. Ann Surg. 2004;239(1):14.
2. Barbash GI, Glied SA. New technology and health care costs—the case of robot-assisted surgery. N Engl J Med. 2010;363(8):701–4.
3. Owens M, Barry M, Janjua AZ, Winter DC. A systematic review of laparoscopic port site hernias in gastrointestinal surgery. Surg J R Coll Surg Edinb Irel. 2011 Aug;9(4):218–24.
4. Yamamoto M, Minikel L, Zaritsky E. Laparoscopic 5-mm trocar site herniation and literature review. JSLS J Soc Laparoendosc Surg Soc Laparoendosc Surg. 2011 Mar;15(1):122–6.
5. Nezhat F. Minimally invasive surgery in gynecologic oncology: laparoscopy versus robotics. Gynecol Oncol. 2008;111(2):S29–S32.
6. Fader AN, Escobar PF. Laparoendoscopic single-site surgery (LESS) in gynecologic oncology: technique and initial report. Gynecol Oncol. 2009;114(2):157–61.
7. Cundy TP, Shetty K, Clark J, Chang TP, Sriskandarajah K, Gattas NE, et al. The first decade of robotic surgery in children. J Pediatr Surg. 2013;48(4):858–65.
8. Chen MK, Schropp KP, Lobe TE. Complications of minimal-access surgery in children. J Pediatr Surg. 1996;31(8):1161–5.
9. Helgstrand F, Rosenberg J, Bisgaard T. Trocar site hernia after laparoscopic surgery: a qualitative systematic review. Hernia. 2011;15(2):113–21.
10. Hagen ME, Pugin F, Chassot G, Huber O, Buchs N, Iranmanesh P, et al. Reducing cost of surgery by avoiding complications: the model of robotic Roux-en-Y gastric bypass. Obes Surg. 2012;22(1):52–61.
11. Snyder BE, Wilson T, Leong BY, Klein C, Wilson EB. Robotic-assisted Roux-en-Y gastric bypass: minimizing morbidity and mortality. Obes Surg. 2010;20(3):265–70.
12. Uslu HY, Erkek AB, Cakmak A, Kepenekci I, Sozener U, Kocaay FA, et al. Trocar site hernia after laparoscopic cholecystectomy. J Laparoendosc Adv Surg Tech A. 2007 Oct;17(5):600–3.
13. Erdas E, Dazzi C, Secchi F, Aresu S, Pitzalis A, Barbarossa M, et al. Incidence and risk factors for trocar site hernia following laparoscopic cholecystectomy: A long-term follow-up study. Hernia. 2012;16(4):431–7.
14. Bell MC, Torgerson J, Seshadri-Kreaden U, Suttle AW, Hunt S. Comparison of outcomes and cost for endometrial cancer staging via traditional laparotomy, standard laparoscopy and robotic techniques. Gynecol Oncol. 2008;111(3):407–11.
15. Cooperberg MR, Ramakrishna NR, Duff SB, Hughes KE, Sadownik S, Smith JA, et al. Primary treatments for clinically localised prostate cancer: a comprehensive lifetime cost-utility analysis. BJU Int. 2013;111(3):437–50.
With the expectation of a sharp rise in the volume of robot-assisted procedures in the future, it is likely that the complexity of cases being performed robotically will increase. The availability of a greater range of instruments, accessories, and medical devices customized for use with robot systems will facilitate this shift in approach...