Authors: Shi Yusheng, Peng Chenghong
Source: Chinese Journal of Hepatobiliary Surgery, 2024, 30(5)
summary
Robotic surgical systems, introduced in the late 20th century, have been in clinical practice for more than 20 years and cover almost all surgical procedures. Robotic surgery has many advantages such as less trauma, more precision, and faster recovery, and has become the first choice for the vast majority of patients with benign or low-grade malignant tumors. However, despite the many advantages of robotic surgery, there are still shortcomings or controversies in its clinical use, and there are many problems that need to be solved urgently. Since 2009, the author's center has carried out robot-assisted surgery and has completed nearly 3 000 cases of various pancreatic surgeries, accumulated rich experience in surgery and patient management, and has its own knowledge and understanding of some hot issues related to robot-assisted pancreatic surgery at home and abroad. This article takes four current problems in robot-assisted pancreatic surgery as the starting point to talk about my own views.
Robot-assisted surgery was first introduced at the end of the 20th century and gradually developed at the beginning of the 21st century, and has been the most widely used intelligent technology-assisted surgery in recent years. Compared with open surgery, robot-assisted surgery has many advantages such as less trauma and high precision, and has been rapidly promoted in various surgical departments since its launch. After decades of development, robotic-assisted surgery has been widely performed in general surgery, cardiac surgery, urology, obstetrics and gynecology [1,2,3,4,5,6,7,8,9], covering almost all surgical procedures, and together with laparoscopic surgery, providing patients with minimally invasive surgical options. Since 2009, the author's center has performed robot-assisted surgery and has completed nearly 3 000 pancreatic surgeries, accumulating rich experience in surgery and patient management. As the first batch of centers to carry out related surgeries in China, it has also witnessed the development process of robotic pancreatic surgery, and also has its own knowledge and understanding of some hot issues related to robot-assisted pancreatic surgery at home and abroad, which are discussed in this paper.
1. Can robotic surgery completely replace open pancreatic surgery?
This issue has been controversial since the introduction of robotic surgery. Robotic surgery has incomparable minimally invasive advantages compared with laparotomy surgery, traditional laparotomy pancreatic surgery generally requires 20~30 cm according to the different tumor location, nature and size, compared with robotic surgery, the trauma is small, only 5 small holes are needed to complete the surgical operation, from the perspective of trauma and patient pain score, it is undoubtedly more conducive to patient recovery, and the above advantages have been confirmed in a number of studies, and have gradually become the consensus of surgeons[ 10,11,12,13,14,15,16,17,18,19]。 The author's center has taken robot-assisted pancreatic surgery as the preferred operation for benign or low-grade malignant tumor surgery, not only because of the reduction of trauma, but also because the robot greatly improves the possibility of the surgeon to complete the function-preserving pancreatic surgery, especially the enucleation of pancreatic tumors, which requires surgical instruments to complete the operation accurately, and at the same time completely remove the tumor, protect the normal pancreatic tissue and the main pancreatic duct as much as possible, which depends on the stability and accuracy of the robotic surgical system, which greatly improves the possibility of completing the above operations[20,21]。
However, the author believes that robotic surgery cannot completely replace open pancreatic surgery. Pancreatic surgery is different from gastrointestinal and other general surgery, due to the particularity of the pancreas, which is adjacent to important large blood vessels, so pancreatic malignant tumors are prone to vascular invasion and even need revascularization. The biggest disadvantage of robotic pancreatic surgery is that bleeding is poorly controlled, especially if vascular occlusion is required, and intraoperative bleeding tends to be more time-consuming than laparotomy. In the author's center, neoadjuvant chemotherapy is the first choice for pancreatic cancer patients with potential vascular invasion, and open surgery is still the main treatment after chemotherapy. Moreover, in Chinese mainland, robotic surgery often has a machine usage fee of 3~50,000 yuan, and most of them are not included in the national medical insurance, and not every patient can afford this expenditure. With the continuous development and manufacturing of domestic surgical robots, the cost of robotic surgery may gradually decrease in the future, and more patients are bound to be able to obtain the benefits of minimally invasive surgery.
2. What are the indications for robotic pancreatic surgery? Can robotic surgery achieve a radical cure for patients with pancreatic malignancies?
According to the recommendations of the Chinese Expert Consensus on Laparoscopic or Robot-assisted Radical Pancreatic Cancer Surgery (2022 Edition) and the International Expert Consensus on Robotic Pancreatic Surgery (2023 Edition), robotic or laparoscopic surgery is one of the best options for benign or low-grade malignant tumors of the pancreas. For patients with pancreatic malignancy or venous invasion requiring resectional reconstruction, surgery is recommended by a surgeon who has survived the learning curve [22,23]. Since the pancreas is a retroperitoneal organ, it is located deeper, and from the perspective and field of view, the bottom-up observation direction of robotic or laparoscopic surgery is more intuitive and clear than that of laparotomy, especially in the process of dissociating the uncinate process. In addition, the author's center, because robotic pancreatic surgery started earlier and has accumulated more experience, is currently more inclined to minimally invasive pancreatic surgery. As for the choice of robot or laparoscope, it needs to be comprehensively considered according to the operator's own operation level and habits, as well as the patient's economic situation.
For patients with malignant tumors, the biggest goal of surgery is to achieve a radical cure, which is not only a complete resection of the tumor, but also includes a standard or expanded range of lymph node dissection. The radical efficacy of robotic pancreatic surgery has also been widely questioned, with limited visual field and range of motion sometimes not possible for complete dissection of lymph nodes behind and deep into the blood vessels. According to the author's experience, deep lymph nodes including group 16a/b, group 9 and Heidelberg triangle can be completely dissected by robotic surgery system within the standard lymph node dissection of pancreatic cancer, and even when dissecting the lymph nodes behind the hepatic artery and the Heidelberg triangle, it is even easier than laparotomy because of the advantage of bottom-up visual field exposure. In several retrospective studies, the radical curative nature of robotic pancreatic cancer surgery has been demonstrated [24,25,26,27]. In contrast, in two recently published randomized controlled studies of robotic-assisted pancreaticoduodenectomy for pancreatic cancer, there was no significant difference in the number of lymph node dissections between robotic and open surgery, and long-term follow-up results have not been published, providing a more accurate evaluation of the curative nature of robotic pancreatic surgery [28,29].
3. What are the advantages of robotic surgery over laparoscopic surgery?
The birth of laparoscopic surgery is about 20 years earlier than robotic surgery, which has opened the door to minimally invasive surgery. Robotic surgery started late, and in terms of surgical approach and surgical method, it actually borrowed a lot from laparoscopic surgery, and there is no essential difference between the two.
The main advantage of the robotic surgical system is the flexibility and ease of use of the instruments, as the tip of each robotic arm can move 720° to simulate the joints of the human hand, allowing the surgeon to be more flexible during operation, especially in surgeries that require vascular or gastrointestinal reconstruction. In recent years, the author and his colleagues still prefer robotic surgery as the first choice for minimally invasive surgery because of the fact that robotic and laparoscopic pancreatic surgery are carried out almost simultaneously in the early stage of surgery, and in the early stage of surgery, robotic surgery is superior to laparoscopic surgery in terms of surgeon's physical exertion and fatigue [30,31,32,33]. However, there is no doubt that there are certain disadvantages of robotic surgery, first of all, due to the overall needs of national planning, not every large tertiary hospital is equipped with a robotic surgery system, even if it is equipped, most of them are only one, pancreatic surgery takes a long time, and generally only 3~4 surgeries can be arranged at most a day, which greatly restricts the development of surgery, which is especially significant in high-flow centers; Secondly, the overall cost of robotic surgery is 3~40,000 yuan higher than that of laparoscopic surgery, and it cannot be included in medical insurance, so the burden on patients is heavier. Therefore, the author believes that for pancreatic surgery, especially high-flow pancreatic centers, robotic, laparoscopic, and open surgery should be reasonably selected to better allocate medical resources and provide patients with different needs with the most suitable high-quality medical services.
4. What are the intraoperative precautions for robotic surgery?
Due to the particularity of robotic surgery, it is necessary to carry out operation training before carrying out both domestic and foreign operations to ensure the safe and effective operation of the operation. The training includes two aspects: assistant training, which focuses on robot installation and intraoperative adjustment, and master knife training, which focuses on the familiar use of specific operating systems. In specific clinical use, the author has accumulated some of his own experience in view of the particularity of pancreatic surgery, and I will share it here.
1.Layout of the Trocar:
At the beginning of the launch of the fourth-generation da Vinci robot, Intuitive suggested that the Trocars be laid out in a straight line, about 8 cm apart from each other. In the author's center, the experience of robotic surgery comes from the second and third generation da Vinci robots, and the Trocar layout is fan-shaped and the distance is as large as possible. Both methods have been tried, and in contrast, the fan distribution is more conducive to the deployment of the instrument, expanding the range of motion, and thus obtaining the maximum operating space. At the same time, the lens hole of the fourth-generation robotic surgical system is different from that of previous generations, and the system will automatically recognize the distance between the lens and the Trocar, so it should be avoided to insert the Trocar too deep when using, otherwise it is easy to limit the space for lens movement.
2. Use of Ultherapy:
Ultherapy is one of the commonly used instruments in robotic pancreatic surgery, which has a good vascular coagulation effect and is more suitable for dissecting peripancreatic tissues than electric hooks or electric scissors. However, it is necessary to take care to protect the surrounding tissues, especially blood vessels or other important structures. Ultherapy is divided into working surface and protective surface, the working surface is at a high temperature during and after working, and it is easy to cause accidental injury if the operation is improper, especially in the process of anatomical separation of paravascular tissues or lymph node dissection, once the external sheath or root of the blood vessel is damaged, it will cause vascular damage that is inconvenient to deal with, and even postoperative pseudoaneurysm. In the process of using the ultrasonic knife, the author will rotate the cutter head slightly, so that the protective surface touches the blood vessels or tissues that need to be preserved as much as possible, so as to avoid thermal damage caused by the working surface. For stripping of the vascular sheath and similar procedures, sharp separation with scissors is used instead to protect the tissue.
3. Flexible replacement of instrument position:
The biggest change to the 4th generation robotic arm system is that the lens diameter is the same as the other three-arm instruments, so the lens can theoretically be placed anywhere in the four holes. Usually the lens is arranged near the umbilical foramen, but in some practical scenes, such as the anterior anatomy of the inferior vena cava behind the duodenal frame (preserving the duodenum), the dissection of the upper pole of the spleen (preserving the spleen), and the use of a cutting and closing device but the angle is limited, we should flexibly adjust the position of the lens to achieve the best operating space and operation effect.
5. What is the future development direction of robotic surgery?
Robotic surgery has been launched and developed for more than 20 years, and the da Vinci surgical robot of Intuitive Company in the United States is currently the main product on the market, which is basically in an industrial monopoly position, and the cumulative number of surgeries has reached hundreds of thousands, which is accepted by most hospitals and patients, and the benefits brought to them are obvious. The industry has fed back research and development, and the da Vinci robotic surgical system has also been updated and iterated many times, and the fifth-generation model has been launched, and at the same time, surgical systems for specific scenarios such as single-port surgical robots have gradually emerged, expanding the surgical indications.
In the clinical application of robotic surgical systems, there are still some problems that need to be solved urgently: (1) lack of force feedback. In surgery, force feedback is very important to determine the tightness of the sutures or the force of squeezing the tissue, and to avoid accidental damage caused by too loose sutures or excessive compression of the tissue. Since the development of robotic surgery, there is no force feedback system that can be applied to clinical practice, and the author's supervisor, Professor Peng Chenghong, has proposed the concept of "visual force feedback", which makes up for the shortcomings to a certain extent, but it also needs to be obtained after a certain amount of time and experience accumulation. According to the latest reports, the fifth-generation da Vinci surgical robot has a force feedback function, but whether it can be used flexibly still needs to be proven in practice. (2) Expansion of telesurgery. Robotic surgery was originally developed to provide surgical treatment to astronauts in outer space or space stations, and remote surgery was one of the main goals when it was first designed. Due to many problems such as data transmission delay and signal acquisition, remote surgery has not been able to make breakthroughs. In recent years, with the strong support of the state, some domestic robotic surgical system manufacturers have gradually made breakthroughs in this regard, and are expected to achieve corner overtaking. With the support of 5G network, many hospitals in China have completed robot-assisted remote surgery, including cholecystectomy and liver tumor resection, all of which have been successful, accumulating initial experience and laying a good foundation for the next step of more complex remote surgery, especially pancreatic surgery.
6. Summary
The birth of the robotic surgical system has opened a new chapter in precision surgery, which, together with laparoscopic surgery, provides patients with a less invasive and faster recovery surgical method. With the continuous development of science and technology, the application scenarios and application fields of robotic surgery will become more and more extensive, and more and more medical methods that have not been conceived before will gradually enter the public eye. However, the treatment of tumors, the safety of patients and the improvement of quality of life are the eternal goals of surgery. There is no doubt that there are still many deficiencies and deficiencies in robotic surgery, and surgeons will work with the R&D team to gradually explore and accumulate experience to create a better future for robotic surgery.
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