Robotic-Assisted Surgery with the daVinci-System

Robotic surgical systems are often used to perform minimally invasive procedures. The daVinci surgical system is still one of the market leaders and is especially well suited to perform prostatectomies, a surgical option for prostate cancer.

In this MEDICA-tradefair.com interview, Professor Bolenz explains when and how this surgical system is used in the operating room.

What benefits does robotic-assisted surgery with the daVinci surgical system offer patients?

Prof. Christian Bolenz: The method is minimally invasive, which is one major benefit experienced by patients. So-called keyhole surgery results in less trauma to the body as it is done through a tiny incision, which leaves smaller scars and typically allows for a faster recovery after the procedure. Radical prostatectomy, for example, can cure prostate cancer. Using a minimally invasive surgery technique in this setting results in less blood loss to the patient compared to an open surgical procedure. This, in turn, causes reduced transfusion rates and earlier mobilization of the patient after the surgery. Early mobilization after surgery also reduces the risk of venous thromboembolism and allows a faster return to normal bodily functions.

What are the advantages of robotic-assisted surgery with the daVinci surgical system for surgeons?

Bolenz: The system allows advanced HD visualization with up to 10x magnification, which provides surgeons with a more immersive view of the operative field and specific structures compared to the open surgical procedure. They system's ergonomic design is also a great benefit. The surgeon operates while seated comfortably at the surgical console. He or she can adjust the height of the seat and the armrest.

Another positive aspect is that teaching is made easier during surgical interventions performed in colleges or in front of medical students. Thanks to the monitor, surgeons can show and explain surgical steps and techniques in real-time. This is not an easy feat during an open surgical procedure, as pelvic surgery is usually performed in the pelvic cavity, making it more difficult to accurately show structures and surgical steps.

Is there still room for improvement and development when it comes to robotic-assisted surgeries?

Bolenz: Systems are becoming even less invasive thanks to so-called single site or single port surgery where two or more conventional ports are placed through a single-incision. However, this requires more sophisticated instruments that are technically complex and even more expensive. One enhancement in this area are instruments that unfold once inside the body, thus making it possible to hit the right angles for the procedure.

Another trend is to improve intraoperative navigation assistance and imaging during surgery. For example, you can light up specific structures or mark areas using certain substances. These markers allow surgeons to distinguish normal from malignant tissue on-site and cut away accordingly. There are also efforts to enable haptic (tactile) feedback for the surgeon. When the surgeon sits on the surgical console, he or she cannot feel the tissue and must, therefore, make a visual assessment of the structures. The feedback option lets surgeons know whether the tissue is hard or soft. Someone who is very experienced in open surgery and then switches to the daVinci surgical system is usually able to assess the texture of the tissue. That’s why this option would especially benefit surgeons who are new to this method or are less experienced in open surgery.

When does it make sense to use the daVinci surgical system?

Bolenz: The daVinci surgical system offers great benefits, especially when it comes to surgeries in the pelvic area. In fact, it has been adopted as the standard approach for this type of intervention. The surgical system is especially useful in operating fields that are located in deep and very tight cavities, including the removal of rectal cancer or prostate cancer and where subsequent reconstruction is needed. The reconstructive component in this type of surgery is a key criterion for using the daVinci surgical system. Sutures in deep cavities require the surgeon to have enough room to navigate the suture needle. This surgical method has very quickly established itself as the best radical prostatectomy technique (removal of the prostate gland).

How do surgeons learn to perform robotic surgery?

Bolenz: There are structured training concepts that are increasingly being standardized by the professional societies. The concepts usually imply that surgeons already have some open surgery experience before they are introduced to the method using various models and simulators.

Intuitive Inc. is the maker of the daVinci surgical system and offers a structured, partly online training program. It ranges from various theoretical continuing development programs to simulation training. The selection includes surgeries using pigs and surgeries on humans, which are always supervised by an expert.

The German Society for Robot-Assisted Urology is presently building a curriculum that allows respective certification, demonstrating successful completion of the structured training program. It must be emphasized that the surgical robot cannot operate autonomously without the control of a surgeon. This robotic-assisted system is a high-precision tool that is only as good as the surgeon and can thus only achieve what the surgeon is capable of accomplishing.

What are the risks of robotic-assisted surgeries?

Bolenz: I don't see any actual higher or increased risks compared to open surgery. There are some contraindications - such as someone suffering from cardiac insufficiency, chronic lung disease or patients who had major previous surgeries in the operative field slated for keyhole surgery- that might argue against the use of robotic-assisted intervention. It is more a question of how comprehensively you want to apply and can afford to use this method. I think there is a greater risk if the system is broadly used for all surgical procedures, even though it might not be particularly beneficial or helpful in certain interventions. Minimally invasive robotic-assisted surgery should only be an option for those patients and types of surgeries where this procedure makes practical sense and offers true advantages.