Pure laparoscopy involves entering the abdominal cavity through tiny incisions (about 1/2") using a camera and small instruments for manipulation. The abdomen is filled with carbon dioxide, a harmless gas, in order to create a working space for visualization in the abdomen.
Laparoscopy was initially used in the field of gynecology, first for diagnostic procedures, and later for treatment of many conditions. Subsequently, laparoscopic cholecystectomy became the approach of choice for removal of the gall bladder. In 1991, the first kidney removal was performed with the laparoscope. Today, this technology is used for many urological procedures, including radical nephrectomy (removing the entire kidney), partial nephrectomy (removing a tumor from the kidney and leaving the rest of the kidney in place), adrenalectomy (removal of the adrenal gland), and varicocelectomy (correcting varicose veins in the scrotum), among others.
The advantages of laparoscopy include being able to perform complicated procedures inside the body through tiny incisions, reducing the trauma of large incisions. This leads to lower levels of pain after surgery, faster recovery, and lower blood loss compared to open surgery. In addition, the camera is able to be positioned close to the target organ within the body, providing for high magnification and superior visualization.
One major disadvantage of pure laparoscopy is that the instruments have only limited range of motion, making complicated reconstruction within the body, such as is required during laparoscopic prostatectomy, very difficult to perform. This is analogous to trying to tie your shoes with casts on both of your wrists. This is the primary driving force for the evolution to robot-assisted surgery, as described below.
Robot-assisted surgery is an evolution of laparoscopic surgery, allowing the performance of more advanced surgical procedures with greater accuracy and dexterity than pure laparoscopy. As with pure laparoscopy, a camera is inserted into the abdomen and carbon dioxide is used to created a working space. However, the robotic system has several key advantages over pure laparoscopy, as outlined below:
- Instruments: Robotic instruments have tiny wrists at the tip, providing for 6 degrees of freedom (the same or better than the human wrist). This provides for superior dexterity and allows for complicated reconstruction within the body. This is a great feat, considering that the tips of the instruments are only about 1/2" in size.
- Camera: The robotic camera has 2 separate cameras offset slightly, just like our own eyes, in order to provide the surgeon with true 3-dimensional visualization. Combined with up to 12x magnification, this provides superior ability to distinguish important structures within the body.
- Ergonomics: During robot-assisted surgery, the surgeon sits at a console at the patient's bedside in a comfortable position. This allows the surgeon to perform the surgery without the same extent of physical fatigue encountered during open or laparoscopic surgery.
The only complete robotic surgical system (da Vinci®) currently available is made by Intuitive Surgical, Inc. This system is essentially a master-slave system that translates the surgeon's hand movements outside of the patient into movements of the miniature robotic instruments inside the patient. The word “robot” often implies automated movements by a computer. This is a misnomer as the robotic instruments do only as the surgeon directs, without any automated movements.
The da Vinci surgical system was FDA approved for patient use in the year 2000, and the first robot-assisted prostatectomy was performed in 2001 Initially, radical prostatectomy for prostate cancer was the only surgery performed robotically, but as surgeons became more comfortable with the new technology, they began to adapt the system to other surgeries. Today, there are many surgeries being performed in urology as well as in several other surgical fields, including gynecology, general surgery, thoracic surgery, and cardiac surgery.
The robot requires specialized training to operate. Initially, only major academic centers were able to operate the system. However, with increasing experience nationwide, those trained in the technology have become more widespread; smaller academic centers and even some community hospitals have been able to establish top-notch robotic programs.
At Capital Region Urology, we were the first urologists to become trained in this technology in the Capital Region. St. Peter's Hospital in Albany acquired the da Vinci system in 2004. In 2007, Saratoga Hospital started a robotics program with the da Vinci system under the guidance of Dr. Seth A. Capello, who completed a fellowship in robotic surgery at the University of Rochester Medical Center in June 2007.
At Capital Region Urology, we are at the cutting edge of laparoscopic and robotic technology. We are currently performing the following urological procedures using the da Vinci surgical system:
- Radical prostatectomy for prostate cancer
- Radical cystoprostatectomy for bladder cancer
- Pyeloplasty for ureteropelvic junction obstruction
- Ureteral reimplantation for ureteral obstruction
- Partial nephrectomy for renal tumors