Telerobotic laparoscopic cholecystectomy : Initial clinical experience with 25 patients

Computers and technology are increasingly interacting with surgeons both inside and outside of the operating room, as exemplified by the rapid adoption of laparoscopy into routine use. The computer’s ability to enhance, modify, or transform electronic data is changing patient management before, during, and after surgery. As such, these technologic advancements are having an ever-increasing influence on the way surgery is planned and performed. 1–5 We and others have previously reported preoperative liver imaging studies that show computer translation of conventional computed tomography scans into three-dimensional virtual reality images that sharply delineate the patient’s anatomical structures as well as the presence of any pathology. 6–8 By using this model, the surgeon can choose dissection planes before and during surgery. This significant advance in imaging technology has led to image-guided surgery in specialties such as neurosurgery and has led to an increased interest in computer-assisted surgery (CAS). 9,10 To gain intraoperative benefits from virtual reality imaging, the entire surgical operation must be transformed into a form of communication that can be integrated with the information transmitted by real-time imaging. This is accomplished by transforming the movements of the surgeon’s instruments into electronic signals, or digitization, a form of communication that can be processed by a surgical robotics computer system. As an initial step in this evolution in surgical planning and intraoperative interaction of surgeon with the computer, the present study was designed to determine the feasibility, safety, and utility of performing laparoscopic cholecystectomies with the computer–surgeon interface of a surgical robotic system. The robotic system duplicates the motion of the laparoscopic instruments controlled by the surgeon, who is positioned at a distance from the patient; using this system, laparoscopic cholecystectomies were performed in both acute and nonacute clinical situations. Establishing the safety of performing robotic procedures on abdominal internal organs will pave the way for future definitive studies of computer integration of preoperative imaging studies with real-time, computer-assisted surgery. CAS offers several advantages: the increase in three-dimensional accuracy, the reproducibility of repeated procedures, the increased precision of movements, and the unique ability to perform surgery over a distance. 11 The robotics systems currently in use, including the system described here, operate on a master/slave principle that involves the use of a “master” computer console operated by the surgeon that integrates computer input, manipulation of the master instruments that control the endoscopic instruments, and the “slave” instruments that are attached to and manipulated by the robotic control arms. 12–15 This is considered computer-assisted “passive” robotic manipulation because the robot is under the direct control of an operating surgeon. Therefore, the robot does not replace but rather augments the skills of the surgeon. As an initial clinical study on robotic-aided surgery to establish safety and feasibility, further aims of this study were to determine the practicality of the use of the robot by operating room support staff and surgical staff; location of ports for optimal placement of robotic-controlled instruments to optimize visualization and to minimize opposition of the instruments; and finally to compare postoperative course and patient outcomes with literature standards for laparoscopic cholecystectomies.