Robotic Foregut Surgery

Laparoscopy and minimally invasive operative techniques revolutionized abdominal surgery, beginning with the first laparoscopic cholecystectomy in 1987 (Mouret, 1996). Patients, surgeons, and industry alike have promoted the application of these techniques to a wide range of procedures. Smaller incisions and less abdominal wall trauma contribute to improved cosmesis, shorter hospitalizations, less pain, and quicker recovery than is observed following open procedures. Laparoscopic techniques have been widely adopted in a variety of foregut procedures. The laparoscope has allowed surgeons to visualize areas that are more difficult to see in standard open procedures such as the gastroesophageal junction or the diaphragmatic hiatus. These factors have contributed to a population-based rate of antireflux surgery that more than doubled in the United States between 1990 and 1997 (Finalyson, et al, 2003). Several limitations inherent to a laparoscopic approach have prevented its widespread use in some areas of general surgery. The visualization during laparoscopic surgery is typically two-dimensional and limited by camera operator fatigue and abrupt movements. There is diminished tactile feedback, and complex maneuvers are difficult secondary to fixed trocar position and non-articulated instruments. In addition, the length of the instruments amplifies one’s natural tremor at the tip of the instrument. During a standard laparoscopic procedure, surgeons frequently must stand in ergonomically awkward positions for extended periods of time. Surgical robots, or computer-assisted telemanipulators as they are more properly described, allow the surgeon to overcome many of these limitations. Ergonomics are improved as the surgeon sits at a console remote from the patient and manipulates controls for the surgical instruments. The computer eliminates tremor and scales all motions to a selected degree. This allows for very fine and precise movements of the surgical instruments. Since the robotic instruments are multi-articulated and capable of a full range of motion, complex maneuvers are possible. These articulated instruments provide movements similar to the human arm and hand. In addition, high-definition, three-dimensional visualization provides image detail and depth superior to that of a standard laparoscopic system. The camera is manipulated by a robotic arm controlled by the operating surgeon. These features translate to certain advantages during complex foregut procedures when compared to a standard laparoscopic approach. O pe n A cc es s D at ab as e w w w .ite ch on lin e. co m