Volume 17, Issue 4, April 2003, Pages 574-579
Comparison of laparoscopic skills performance between standard instruments and two surgical robotic systems
Dakin, G F; Gagner, M
Division of Laparoscopic Surgery, Department of Surgery, The Mount Sinai School of Medicine, Box 1103, 5 East 98th Street, 15th Floor, New York, NY 10029, USA
BACKGROUND: Our objective was to compare the performance of laparoscopic tasks by surgeons using standard laparoscopic instruments and two surgical robotic systems. METHODS: Eighteen surgeons performed tasks in a training box using three different instrument systems: standard laparoscopic instruments, the Zeus Robotic Surgical System, and the da Vinci Surgical System. Basic tasks included running a 100-cm rope, placing beads onto pins, and dropping cotton peanuts into cylinders; fine tasks included intracorporeal knot tying and running stitches with 4-0, 6-0, and 7-0 sutures. Time (in seconds) required and precision (number of errors) in performing each task were recorded. Analysis of variance with pair-wise comparisons using the Bonferroni method and Friedman's nonparametric test were used for statistical analysis. RESULTS: Standard instruments performed significantly faster than either robotic system on the rope and bead tasks (p <0.05), whereas da Vinci performed significantly faster than Zeus in all three basic tasks (p <0.05). No significant difference in precision was found between standard instruments and the robotic systems on any of the basic tasks. Knot-tying and running-suture time were similar between standard instruments and da Vinci, which were significantly faster than Zeus (p <0.05) for all suture sizes. The robotic systems were similar in precision for fine suturing tasks and were significantly more precise in knot tying (Zeus and da Vinci) and running sutures ( da Vinci) than standard instruments (p <0.05). CONCLUSIONS: Basic laparoscopic task performance is generally faster and as precise using standard instruments compared to either robotic system. In performing fine tasks, neither robotic system is faster than standard instruments, although they may offer some advantage in precision.<<
NEH, As usual, a very coherent position. You wrote:
>>I've learned a long time ago never to question the possibility/ability of "sensors," e.g., measuring blood flow by voltage (i.e., Micron Blood Flow Meter) but I don't think I will ever keep from questioning "mechanical" things. That's why I question a 'mechanical' solution for the backside of the heart and the tracking of a beating heart (including PVC's) with mechanical arms. I guess it can and will be done, but I think it's a way down the road.<<
The thought of a needle or, even worse, cautery or a scalpel adjacent to or within the myocardium of a patient in NSR (makes tracking resonably simple-rate and cardiac movement are fairly predictable) with a clamp or silastic suture around the coronary artery to facilitate anastomosis is OK. For someone with prolonged coronary occlusion (causing localized ischemia) or any sort of unpredictable arryhthmia, scares the heck out of me - I'm not an engineer either but I'm assuming there's some lag (around 0.3-0.5 sec) between sense and response. Yikes!!!!! Its enough to make me want to go to law school so I could become a patient plaintiff's attorney. Even better, an expert witness testifying against greedy device companies (look no father than Guidant) and unsavory doctors taking money under the table from ruthless marketing types. I need to take my meds, Ser
But thanks anyway for the interesting links
Another link that I forgot to put up is:
It's a new area and probably a good bookmark for those investors into the blood & guts part of things.
As far as the back side of the heart, I think that is going to be way down the road and I don't believe it will ever be accomplished (at least as a standard procedure) without the chest cracked. I'm thinking (and maybe not even in our lifetime) the 'tool' will be a scaffold affair to support and lift the heart up... maybe with help of suction, i.e., MDT's Octopus. Then the thought is 'Why use robotics?' That's why I say not in our lifetime. I suspect as robotics progress, using robotics as a tool may end up being more beneficial than hands-on. I also think there needs to be a lot more evidence of a clearly defined 'big' advantage of beating heart vs stopped heart on multivessels. I guess what I am saying is that they need to get the easy stuff done right first.
On a similar note... I understand that ISRG has been working on synchronizing the robotic arms with a beating heart for some time. In other words, eliminate or partially eliminate the stabilizer by tracking the movement of the beating heart and moving the instruments in sync. This type of stuff has/is being done with the intraaortic balloon pumps, synchronized off BP or ECG. Wang (RBOT) has mentioned tracking devices that sensed via visual feedback (but during that time he concluded too expensive). I questioned if the servos could react that quickly and have been assured they can... especially well suited for the da Vinci due to the cable/pulley design (less hysteresis).
As we probably recall, ISRG and MDT are working on 'products' together and I suspect a big part of this is the stabilizer (MDT's Octopus) which at some point will not be just a passive device but rather an active device (maybe tracking the heart and possibly working like an active 'noise canceling device,' i.e., inverse feedback).
I've learned a long time ago never to question the possibility/ability of "sensors," e.g., measuring blood flow by voltage (i.e., Micron Blood Flow Meter) but I don't think I will ever keep from questioning "mechanical" things. That's why I question a 'mechanical' solution for the backside of the heart and the tracking of a beating heart (including PVC's) with mechanical arms. I guess it can and will be done, but I think it's a way down the road.
Another thing that keeps creeping into my head is that docs like a "solution" that fits most cases. If the product will work on most patients, fat, skinny, short and tall, it's an easier sale.
As far as, >> ...Europeans are always ahead of us in innovation - thanks to shifty-eyed, GD lawyers and regulatory restrictions. <<
I had a friend move back after living years in California because he couldn't afford to live there on his retirement. After a couple of months he asked, "Why do you guys have so damn many pot holes?" My answer was, "Because you can buy an $800,000 house here for $200,000."
I'm still not sure if regulations are a good thing or bad thing... but at least 3/4 of the cost seems to go to lawyers.
Evil and NEH, Thanks for the posts, seems like the Europeans are always ahead of us in innovation - thanks to shifty-eyed, GD lawyers and regulatory restrictions. Please remember I'm no a CT guy by any stretch of the imagination - specialists and sub-specialists do stuff every day that I'll see for the very first time on Nova just like you. Enough homage to CTV surgeons..... I must admit it may be less critical to do more than 2 vessels now given the advent and acceptance of stents. Its true as NEH pointed out in his post (from Mack) that stents are both a bane and a boon - lots of disease can be treated with stents - its simply not the way to go with ALL disease given the heterogenity of patients, presentation of primary lesions, and prevailing co-morbidities. As such, if the surgeons want to keep their business, they will have to devise a multi-vessel (ultimately off-pump) option to compete in the clinical marketplace (unless of course stents are found to cause some other pathology, like impotence or hairy warts). And yes, you're correct in saying lets just do a minimally invasive on-pump procedure and accept that as a viable alternative to sternotomy for those needing multiple grafts. Its just not the fairy tale story we'd like to offer patients.....but it still beats a stem-to-stern sternotomy. Ser
serotoninonboard: There are a few centers doing BH CABG in europe. I don't know how many (if any) are doing this in the US. Single and double vessel are certainly possible, and they have been doing this for some time (a few years at least) in Europe using stabilizers, etc. Posterolateral vessels off-pump are difficult. I know it was tried a few years back, but don't know if it was very successful. Special retractors or stay sutures may help. Do you think it's necessary to do more than 2X CABG off-pump? I would think that if you've got 3X or more, you'd just go on-pump and get it done???
Here is the direct link to what you two are talking about:
Also, let me point out two news releases (which they might be taken down after the merger)...
1st is world's first beating heart robotic bypass (Canada) http://investor.computermotion.com/news/19991006-71809.cfm
2nd world's first multivessel robot bypass (Germany)
I don't know if you guys listen to any of the "debates" on CTS, but they are great! I haven't heard a lot from Dr. Mack (in Dallas) lately but during the time of this debate he probably had more beating heart 'studies' under his belt than anyone. He was involved in concurrent studies that goals were each slightly different, one of which was with the Zeus.
Also, I can't remember if this debate was the debate where he talked about beating heart hemodynamic stabilization (which he concluded to stabilize the abnormal pressure during beating heart surgery, was to move the "patient" and not the heart until stable) but one of these debates is where he talks about this to some degree. The design of the Zeus allows this ability during surgery.
I believe this is a pretty good debate and it was sort of screwed up since they couldn't get the "other side" of the original debate of, "Is MIS better than conventional." So it was changed to "Is MIS better on a Stopped heart or Beating heart." Also, if I recall, this may be the debate where Mack goes-off on the cardiologists taking away surgeons business via the 'stents' plus ends up leaving a mess for the surgeon at a later point. I thought you might especially get a kick out of this one, mbergman.
It's lengthy but a fun listen:
Actually 5 different audio files.
Hi MB, I looked at the Dogan reference from JTCS you pointed me to in your least message. This group described their initial experience with mostly single vessel grafts (n=37) and apparently double vessel (n=8 LIMA & RIMA grafts). While I can see the amazing benefit of training (decrease in operative time and conversions with increasing case #), I'm still lost as to how they intend to do posterolateral vessels off-pump. Your point abount cardiac output is well taken - is it plasuble to use pump-assist. I know multi-vessel on-pump can be done using various retraction devices but this clearly necessitates additional (maybe larger) incisions. Anyway thanks for the ref, I'll look around some more - it appears there are another couple of Euorpean Centers doing da Vinci CABG (Cichon?) as well as a couple in the U.S. (Coumbia, OSU). I don't know if they're on- or off-pump though. Ser
Lets look at bots against the hand. We have 2 surgeons,1 bot trained, in the same room. They each have 3 patients to operate on in 2 days. The first patient is in the same room. The next patient is in Anaractica and the last patient is in Russia. Which surgeon will get through first?
>> The first patient is in the same room. The next patient is in Anaractica and the last patient is in Russia. Which surgeon will get through first? <<
I'm not real good at these since we had sort of the same thing in psychology about guys in a boat and I didn't do so well, but here's my stab at it:
My first guess would be the Rabbi but I think that is a long shot, and I'd rule out the Priest... so I guess I'll have to go with the Lawyer. I'm I right?
The best I can recall it's because Lawyers don't live in Antarctica?
The problem with on-pump CABG is the complexity of the aortic occlusion and venous drainage procedure needed to accomplish this without open access. It can be done but it is cumbersome. As to the back of the Left ventricle, this is easier with by-pass because you don't interfere with the cardiac output by displacing the heart. Off-pump it is a problem and I really don't know how exactly it is accomplished. I have a reference for you - Journal of Thoracic and Cardiac Surgery Vol 123 pp 1125-1131 from a German group details their initial 40 some cases with DaVinci. Hope this helps. Will it play in Peoria? I don't know - it requires a huge investment in equipment, time, team, dog (pig?) lab to get started. MB PS: Look at www.ctsnet.org
Berg, Good to hear you're a CT surgeon....I have a couple of questions. My thinking posed a month ago or so is that the consuming public (surgeons and patients) would accept single or multi-vessel CABG procedure on pump. Not as good a story as off-pump but better than an intercostal approach and far better than a sternotomy approach. What do you think - as a community surgeon not as an academician - could you sell it in Peoria? Second, one thing my friend and I have pondered (for at least 2 minutes) is how will the CT guys get to the dark side of the moon, i.e., the posterolateral vessels with traction - 4th arm, through non-daVinci accessory ports? Thanks, Ser
Hi Ser: Yes, retired cardiothoracic surgeon, just fascinated by all the new toys and wish they had been there twenty years earlier. I bought a very little rbot and isrg just for the fun of hearing about the toys. Certainly haven't made any money yet, but that was a secondary consideration, considering my stake is less than 1 k. MB