REVIEW ARTICLE Kor J Spine 7(2):61-65, 2010
Current and Future of Spinal Robot Surgery 1
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Moon Sool Yang , Jin Hwan Jung , Jae Min Kim , Choong Hyun Kim , 2 2 2 2 Seong Yi , Yoon Ha , Keung Nyun Kim , Do Heum Yoon 1
Department of Neurosurgery, Guri Hospital, Hanyang University College of Medicine, Guri, Korea Department of Neurosurgery, Spine and Spinal Cord Research Institute, Yonsei University College of Medicine, Seoul, Korea
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Objective: To review the current applications of robotics in spinal surgery. Methods: We reviewed the literature on robotic surgery identified by searching Pubmed. Articles reporting clinical results of ® robotic surgeries using the da Vinci surgical system were analyzed. Descriptions of our trials and comparisons with the conventional techniques were added to the review. Results: Several surgical robots have been developed however, most of the robots are currently unavailable for practical ® use. Most of publications regarding spinal surgical robots merely suggested its feasibility. The da vinci surgical system is the popular robotic system designed for use in various surgical fields. However, clinical applications of this innovative instrument in spinal surgery seem to be in the experimental phase. According to our research, the advantages of robotic ® surgery using the da Vinci surgical system were maximized in cases of paravertebral or presacral tumors however, its use in other types of spinal surgeries such as the transoral craniovertebral junction approach andanterior lumbar interbody fusion will be feasible in the near future despite the current limitations. Conclusion: Clinical application of robotic surgery in the spinal surgical field is currently confined to the treatment of some specific diseases or procedures however, robotic surgery is expected to play a practical future role as a minimally invasive surgical instrument in spinal surgery. Key Words: Robotics • Minimally invasive surgical procedures • Spine
INTRODUCTION Today robots substitute for human forces to perform many specific, precise, dangerous tasks in industry and battlefield. Robots meant dumb machine which performed repeatitive, menial works without intelligence in the past, but the robotic technology has repeated remarkable achievements for several decades. Furthermore, robotic technology is getting into the human body. Human surgery is not a simple, repeatitive but a very complicated work and unexpected situations are often confronted with during surgery. Robots cannot perform surgery without any help if the robots were to have human ● Received: June 2, 2010 ● Accepted: June 12, 2010 ● Published: June 21, 2010 Corresponding Author: Yoon Ha, MD Department of Neurosurgery, Yonsei University College of Medicine 134 Shinchon‐dong, Seodaemun‐gu, Seoul 120‐752 Korea Tel: +82-2-2228-2150, Fax: +82-2-393-9979 E-mail:
[email protected]
intelligence. Therefore, surgical robots have a practical role in reinforcement of the human ability performing precise surgical procedures by ameliorating the limitations of surgeon’s skills. Although robotic surgery is an interesting and emerging item in various surgical fields, the effectiveness of the device is still under debate1,2,5) The goal of this article is to review the current robotic systems and applicability to spinal surgery, to review the advantages and disadvantages of currently most famous robotic system ‘da Vinci surgical system®’. Preliminary clinical results of ours were discussed after the review.
CURRENT ROBOTIC SURGICAL SYSTEMS Frameless stereotactic radiosurgical instrument such as cyberknife is a robotic surgical system in a broad sense12). However, stereotactic radiosurgery is widely used for treatments of spinal tumors but, the indication is restricted to specific disease. Complement image‐guided surgical robots for brain Kor J Spine 7(2) June 2010
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biopsy, endoscopic ventriculostomy and pedicle screw fixation are also the kinds of robotic surgical systems3,6,17,32,36). Supervisory‐controlled robotic systems for presice procedures such as pedicle screw fixation have been developed and experienced in vivo or human clinical trials. SpineAssist® was apporved by U.S F.D.A for spinal surgery, but it failed to have the supports by the users. The error range of such an instrument might not prove the excellence because the error between complementary preoperative image and real ana tomyadded to the mechanical error17,29). Another kind of the robotic surgical system originated from the development of tele‐presence surgery. National Air and Space Administration (NASA) of United Sates (U.S) became interested in using virtual reality to develop telepresence surgery in late 1980s. These scientists of NASA team and Stanford Research Institute developed a telemanipulator for human surgery. General surgeons and endoscpists also joined the develoment and realized the potentiality of the system1,7,27). Additionally, the tele‐presence surgical system underwent redesign and technical advances with funding from the U.S Army because the U.S Army was interested in the development of Mobile surgical hospital with tele‐robotic surgical equipments. Today, tele‐presence surgical system such as the da Vinci sugical system® and Zeus® system are marketed and they are actively employed in many surgical fields5,30,35). Especially, da Vinci surgical system® has acquired worldwide currency (Fig. 1). In
Fig. 1. da Vinci surgical robot.
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our country, over 20 robots have been installed since 2007. More than double or triple numbers of the instruments are installed compared with other asian countries. It’s doubtful wheather such an excessive supply results in successful paradigm shift or not. However, a current popularity of the robotic surgical system partly depend on the marketing technique and competitions of major hospitals18).
ADVANTAGES OF ROBOTIC SURGICAL SYSTEM Endoscopists joined the development of tele‐robotic surgical system tried to utilize its advantages by adapting it to the endoscopic surgery. Since the first laparoscopic cholecystectomy was performed in 1987, minimally invasive surgical procedures have improved in almost all surgical fields. Many studies reported its advantages such as less invasiveness to the normal surrounding tissues, better cosmesis, shorter hospital stay, quicker recovery, decreased postoperative infection rate. In spite of the such excellent advantages, laparoscopic surgery could not completely substitute for conventional surgery becau se of several limitations. The laparoscopic surgeon should view a distant monitor which provides 2‐D vision, leading to a change in hand‐eye coordination. ‘Fulcrum effect’ which reverses movements for the surgeon in laparoscopic surgery and restricted movement of the instruments were also obstacles. Because of these limitations, surgeons should undergo steep learning curve for becoming expert. However, after the long training period, other physical problems such as tremor or fatigue can disturb successful surgeries. Robotic surgical system got over the disadvantages of the conventional laparoscopic surgery except one technical problem. Even in the laparoscopic surgery the tactile sense might be reduced, furthermore, we must depend on the only visual informations when using robotic surgical system. Visual feedback can help to avoid serious complication, but haptic function seems to be an essential element for the development of future robotic systems (Table 1). In the spinal surgical field, the role of laparoscopic surgery is extremely limited to a few surgical procedures such as paravertebral tumor resection and anterior lumbar interbody fusion (ALIF). Laparoscopic tumor resection has been attempted and some cases were reported with successful results, but significant surrounding neural and vascular structures often prevented its employment9,11,15,31). Laparoscopic ALIF also provoked tremendous interest among spinal surgeons in the 1990s. Several reports supported the comparable results to open technique8,10). However, laparos- copic ALIF could not demonstrate significant difference or advantage in contrast to conventional
Current and Future of Spinal Robot Surgery
retroperitoneal approach or another minimally invasive procedure such as mini‐open ALIF, what was worse, the rate of complication such as retrograde ejaculation after laparoscopic ALIF was higher than conventional surgery10,13). In addition, disadvantages of the laparoscopic procedures, unfamiliar intraperitoneal anatomic structures, apprehesion about successful fusion also shorten the lifespan of the procedure. In fact, few articles have reported on laparoscopic fusion since the various minimally invasive fusion techniques such as transforaminal interbody fusion came into the fashion. Although laparoscopic fusion technique is a declining method, it still has some advantages over open approach and other minimally invasive fusion technique. Backache, muscle or neural damages may be decreased by using this technique and the disadvantages of the laparoscopic surgery can be diminished using excellent visual cue and improved dexterity of the robotic surgical system. If the robotic surgical system ameliorate the limitations of the laparoscopic surgery, robot‐assisted anterior fusion technique may restorate its position as a minimally invasive fusion technique. Robotic surgical system most efficiently demonstrate its excellences in abdominal or pelvic surgeries at present. Although the effectiveness of this instrument has not been ensured except minimally invasive transperitoneal approach in spinal surgery, robotic surgical system seem to be applied to any lesion if the space for camera and robotic arm is secured and
Table 1. Advantages and disadvantages of Robot‐assisted surgery Advantages Excellent visualization Improved dexterity Tremor elimination Motion scaling Elimination of fulcrum effect Tele‐manipulation Ergonomic position Less infection chance (unproven) Less radiation exposure
Disadvantages Absence of tactile sensation High cost Demand Learning curve Unproven clinical benefit Less flexible than human Hand‐eye coordination
proper Endowrist® instruments are developed. In the spinal surgical field, the instruments for bone‐work is essential, but only proto‐type burr and rongeur were invastigated24). It would be premature to evaluate the effectiveness of the robotic system with successful feasibility study, therefore, clinical trial and analysis of preliminary data are required.
CURRENT APPLICATION IN SPINAL SURGERY Robotic surgery for gynecologic or urogogic tumor became popular, but in the spinal surgical field, tumors outside the vertebral column such as paravertebral or presacral neurogenic tumors are relevant indications. Moskowits et al. reported retroperitoneal transdiaphragmatic robot‐assisted laparoscopic resection of a left thoracolumbar neurofibroma19). Ruurda et al. descibed a case of tumor resection using da Vinci‐assisted thoracoscopic technique26). Even though these operations were performed by cooperation of neurosurgeon and laparoscopic surgeons, if neurogurgeon alerady experienced open approach to the lesion site and if he or she is accustomed with the basic principles of ports placement, robot‐assisted approach doesn’t require steep learning curve such as laparoscopic technique due to its mechanical excellence. We experienced 5 cases of paravertebral or presacral tumor. Three patients complained of numbness or tingling sensation and the other patients had rapidly growing tumors before surgery. We determined the minimally invasive procedures for these patients due to their insignificant symptoms, deep locations and relatively large size. In addition, 2 female patients seriously demanded cosmetic considerations. Total removal of tumor was accompished in all the patients and histopathological examination revealed 3 cases of benign neurogenic tumors, 1 case of transitional meningioma and 1 case of malignant peripheral nerve sheath tumor. The latter 2 cases required longer operation time and larger amount of intraopearative bleeding. In the cases of schwannoma, 90 to 150 minutes and minimal bleedings were
Table 2. Clinical data of 5 patients underwent robotic tumor resection. Sex/age
Location
Op. time (min)
Intraoperative Bleeding (cc)
M/50 M/45 M/42 F/42 M/26
L3‐4 S 1‐2 S1‐3 S2‐4 L1‐2
90 240 120 300 150
